SAGES 2001
Postgraduate Course II
Laparoscopic Bariatric Surgery
April 19, 2001
America's Center
St. Louis, Missouri
Laparoscopic Bariatric Surgery
April 19, 2001
America's Center
St. Louis, Missouri
SAGES Guidelines for Laparoscopic and Conventional Surgical Treatment of Morbid Obesity
ACS Recommendations for facilities performing bariatric surgery
1. Pathophysiology of Morbid Obesity
2. Surgical Treatment for Severe Obesity:Preoperative Evaluation and Selection
Scott A. Shikora, M.D., F.A.C.S.
3. Operative Principles: Setting Up A Bariatric Program
5. Essentials of Laparoscopic Vertical Banded Gastroplasty
6.Laparoscopic Roux-en-Y Gastric Bypass Using a Stapled EEA vs GIA Technique for the Gastrojejunal Anastomosis
S. Ikramuddin M.D., R Ramanathan M.D., W Gourash, CRNP, PR Schauer M.D.
7. Laparoscopic Vertical Banded Gastroplasty with Roux-en-y Gastric Bypass for Morbid Obesity
Aureo L. De Paula, MD and Kiyoshi Hashiba, MD.
8. Laparoscopic Malabsorptive Procedures. Laparoscopic Biliopancreatic Diversion With Duodenal Switch. Technique And Preliminary Results.
Michel Gagner, MD, FRCSC, FACS, Franz W. Sichel Professor of Surgery
9. Hand-Assisted Laparoscopic Roux-en-y Gastric Bypass: Initial Experience
10. Laparoscopic Weight Loss Surgery - Postoperative Care and Long-term Followup
11. Proximal Gastric Bypass Long Term Outcomes
Alan Wittgrove, MD, FACS; G. Wesley Clark, MD
12. Codification of The Lap-band After 1000 Procedures
CADIERE G.B., FAVRETTI F., SEGATO G., HIMPENS J.
13. Laparoscopic Adjustable Gastric Banding: Current Status of the FDA Trial
14. Laparoscopic Gastric Banding for the Treatment of Severe Obesity/ Latin American Experience
15. Complications of Surgery for Severe Obesity
Robert E. Brolin, M.D., F.A.C.S.
SAGES Guidelines for Laparoscopic and Conventional Surgical Treatment of Morbid Obesity
This statement was reviewed and approved by the Boards of Governors of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and the American Society for Bariatric Surgery(ASBS) May, 2000. It was prepared jointly by members of SAGES and ASBS.
Morbid obesity (also referred to as clinically severe obesity) is recognized as a major public health risk throughout the world. In the U.S.A. alone, over four million people suffer from this chronic disease. Much of the associated morbidity and mortality is related to co-morbid conditions which include, but are not limited to , cardiac disease, diabetes mellitus type II, obstructive sleep apnea, hypertension, dyslipidemia, gastroesophageal reflux disease, stress urinary incontinence, arthritis of the weight bearing joints, infertility and some cancers.
Surgical treatment of morbid obesity has been well established as being safe and effective (1). Both short and long-term improvement of co-morbidities has been well documented (2-7). Medical treatment for this disease has included dietary manipulation, behavior modification and medications. These have been tried singularly and in combinations, but with only limited long-term positive results. The National Institute of Health consensus conference in 1991 established widely accepted guidelines and indications for the surgical management of severe obesity (8). The indications for surgical management of obesity are summarized below.
Surgical therapy should be considered for individuals who:
have a body mass index (BMI) of greater than 40 kg/m2
have a BMI greater than 35 kg/m2 with significant co-morbidities.
can show that dietary attempts at weight control have been ineffective.
PERI-OPERATIVE AND LONG TERM MANAGEMENT CONSIDERATIONS
The overall care of patients undergoing bariatric surgery (weight reduction surgery) requires programs which address both perioperative care and long-term management. Careful preoperative evaluation and patient preparation are critical. Patients should have a clear understanding of expected benefits, risks, and long term consequences of surgical treatment. Surgeons must be aware of the diagnosis and management of complications specific to bariatric surgery. Patients require appropriate lifelong follow-up with nutritional counseling and biochemical surveillance. Surgeons need to be aware of the needs of severely obese patients in terms of facilities, supplies, equipment, staff and procedures, and should plan the personal time, specialized staff and/or multi-disciplinary referral system as required. This multi-disciplinary approach includes medical management of comorbidities, dietary instruction, exercise training, specialized nursing care and psychological assistance as needed. Post-operative management of co-morbidities should be directed by the practitioner familiar with the operation performed and the changes created.
Bariatric surgical procedures are divided into two types, restrictive and malabsorptive. With either type of procedure, follow up is imperative to monitor for potential serious sequelae and operative failure. These operations should only be done performed within the confines of an obesity treatment Bariatric program intent on maintaining long-term follow-up as well as long-term outcomes evaluation.
The operations which have been most frequently performed are the Roux-en-Y gastric bypass, vertical banded gastroplasty, the biliopancreatic diversion (BPD) and it's variations, and the various gastric banding procedures (9-13). At the time of this writing, the adjustable silicone gastric banding is limited in its use under FDA protocol. The NIH conference of 1991 recognized the vertical banded gastroplasty and gastric bypass procedures as acceptable procedures based on available outcome data. (8)
Minimally invasive techniques have been used in bariatric surgery since 1993. (14, 15). Laparoscopic bariatric procedures rely on videoscopic technologies to allow surgeons to perform accepted bariatric operations in a minimally invasive fashion. The benefits of a laparoscopic approach appear to be similar to those realized with laparoscopic cholecystectomy, including but not limited to a shorter recovery with an earlier return to normal activity. In addition, wound complications such infections, hernias and dehiscences appear to be significantly reduced.
The indications for laparoscopic treatment of obesity are the same as for open surgery, as and have been outlined earlier in this document. Not all patients are suitable for laparoscopic bariatric surgery, and conversion to an open bariatric procedure is sometimes necessary. Surgeons must have the skills, experience and equipment necessary to convert to and perform open bariatric operations.
Virtually all bariatric operations can be performed with laparoscopic techniques, although advanced laparoscopic skills are required (14-20). For safe and effective laparoscopic treatment of obesity, advanced laparoscopic skills, such as intracorporeal knot tying, use of angled scopes to achieve multiple viewing angles, and two-handed organ and tissue manipulation are required. Therefore, appropriate training in advanced laparoscopic techniques is mandatory. These skills are most appropriately acquired through a residency, fellowship, or courses which detail the indications for bariatric procedures, the various operative approaches -both open and laparoscopic, and the advanced skills necessary to perform these operations. Additionally, the long-term care of these patients needs to emphasized and taught. Before attempting such a procedure independently, the surgeon should be preceptored by a surgeon experienced in the techniques. Finally, these procedures require a well-trained operating team familiar with the equipment, instruments and techniques of bariatric surgery.
Morbid obesity is a significant health concern. Medical management fails to sustain weight loss, and management of the co-morbidities is expensive and often ineffective. Bariatric surgery currently provides the only significant, sustained weight loss. Laparoscopic techniques, based on their "open" counterparts, are available. When performed by appropriately trained surgeons, laparoscopic approaches appear to hasten the patient's recovery and return to normal function. Experience and training in bariatric surgery, advanced laparoscopic surgery skills, and a commitment to long-term patient management are required.
1. Kellum JM, DeMaria EJ, Sugerman HJ. The surgical treatment of morbid obesity. Current Problems in Surgery 1998 ;35: 796-851
2. McGoey BV, Deitel M, Saplys RFJ et al. Effect of weight loss on musculoskeletal pain in the morbidly obese. J Bone Joint Surg (Br) 1990; 72-B: 322-3
3. Charuzi I, Ovnat A, Peiser J et al. The effect of surgical weight reduction on sleep quality in obesity-related sleep apnea syndrome. Surgery 1985; 97: 535-8.
4. Herrera MF, Deitel M. Cardiac function in massively obese patientsand the effect of weightloss. Can J Surg 1991; 34: 431-4.
5. Pories WJ, MacDonald KG, FlickingerEG, et al: Is type II diabetes mellitus (NIDDM) a surgical disease? Ann Surg 1992;215:633-643.
6. Deitel M, Stone E, Kassam HA et al. Gynecologic-obstetric changes after loss of massive excess weight following bariatric surgery. J Am Coll Nutr 1988; 7: 147-53.
7. Carson JL, Ruddy ME, Duff AE et al. The effect of gastric bypass surgery on hypertension in morbidly obese patients. Arch Intern Med 1994; 154: 193-200.
8. Gastrointestinal surgery for severe obesity: National Institutes of Health Consensus Development Conference Statement. Am J Clin Nutr 1992; 55: 615S-9S.
9. Mason EE, Doherty C, Cullen JJ et al. Vertical banded gastroplasty: evolution. World J Surg 1998; 22: 919-24.
10. Linner JH, Drew RL. Why the operation we prefer is the Roux-Y gastric bypass. Obes Surg 1991; 1: 305-6.
11. Scopinaro N, Adami GF, Marinari GM et al. Biliopancreatic diversion. World J Surg 1998; 22: 936-46.
12. Lagace M, Marceau P, Marceau S et al. Biliopancreatic diversion with a new type of gastrectomy: some previous conclusions revisited. Obes Surg 1995; 1: 411-18.
13. Kuzmak LI. A review of 7 years experience with silicone gastric banding for morbid obesity. Obes Surg 1991; 1: 403-08
14. Wittgrove AC, Clark GW, Schubert KR .Laparoscopic Gastric Bypass, Roux-en-Y: and results in 75 patients with 3-30 months follow-up. Obes Surg 1997; 6:500-504.
15. Belachew M, Legrand M, Vincent V, Lismonde M, LeDocte N, Deschamps V. Laparoscopic adjustable gastric banding. World J Surg 1998: 22: 955-63.
16. Chua TY, Mendiola RM. Laparoscopic vertical banded gastroplasty: the Milwaukee experience. Obes Surg 1995; 5: 636-38.
17. Lonroth H, Dalenback J, Haglind E et al. Laparoscopic bypass: another option in bariatric surgery. Surg Endosc 1996; 6: 500-04.
18. Wittgrove AC, Clark GW. Laparoscopic Gastric Bypass: a 5 year prospective study of 500 patients from 3-60 months. Obes Surg 2000; 10: June (in press).
19. Schauer PR, Ikramuddin S, Gourash W, Ramanathan R, Luketich J. Outcomes after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Ann Surg 2000: Oct. (in press).
20. Catona A, La Manna L, Forsell P. The Swedish adjustable gastric band: laparscopic technique and preliminary results. Obes Surg 2000; 10: 15-21.
ACS Recommendations for facilities performing bariatric surgery
[by the American College of Surgeons] The following recommendations were developed by the College's Committee on Emerging Surgical Technology and Education at the request of the American Society for Bariatric Surgery. These recommendations in the evolving field of bariatric surgery have been formulated to assist surgeons and institutions managing morbidly obese patients in providing excellence in surgical care and in developing a safe environment for their patients.
Actuarial data demonstrate that 300,000 Americans die prematurely from obesity-related complications each year. The number of overweight Americans has increased steadily and will continue to increase because more than 25 percent of today's children are overweight or obese. Obesity costs the United States about $100 billion annually in direct health care expenses or in lost productivity.
Morbid obesity is defined as more than 100 pounds greater than normal body weight or a body mass index (BMI) > 40 kg /m2 (BMI > 35 kg /m2 if associated with significant comorbidities), and is present in 5 percent of the US population (10 million individuals). It is associated with many diseases and disorders including diabetes, hypertension, heart attacks, strokes, dyslipidemia, sleep apnea, Pickwickian syndrome, asthma, low back and disk disease, weight-bearing osteoarthritis of the hips, knees, ankles, and feet, thrombophlebitis and pulmonary emboli, intertriginous dermatitis, urinary stress incontinence, gastroesophageal reflux disease, gallstones, and cirrhosis and carcinoma of the liver. In women, infertility, cancer of the uterus, and cancer of the breast are also associated with morbid obesity. Taken together, the diseases associated with morbid obesity markedly reduce the odds of attaining an average life span and raise annual mortality tenfold or more.
Bariatric surgical procedures in current use have been reported to result in marked, lasting weight reduction in the majority of morbidly obese patients when assessed five years after operation. Studies of the health-related quality of life outcomes of these procedures have documented sustained significant improvements in all parameters measured. Diet or drug therapy programs have been consistently disappointing and fail to bring about significant, sustained weight loss in the majority of morbidly obese persons.
Currently, most (95%) morbid obesity operations are or include gastric restrictive procedures, involving the creation of a small (15 to 35 ml) upper gastric pouch that drains through a small outlet (0.75 to 1.2 cm), setting in motion the body's satiety mechanism. About 15 percent of morbid obesity operations done in the United States involve gastric restrictive surgery combined with a malabsorptive procedure, which divides small intestinal flow into a biliary-pancreatic conduit and a food conduit.
Potential long-term problems include not only those seen after any abdominal procedure, such as ventral hernia and small bowel obstruction, but also those specific to bariatric procedures, such as gastric outlet obstruction, marginal ulceration, protein malnutrition, and vitamin deficiencies.
Professional team
Surgeons practicing bariatric surgery are certified or in the process of certification by the American Board of Surgery or its Canadian equivalent within five years after completion of an accredited residency program in general surgery. In addition to obtaining the requisite primary technical expertise, bariatric surgeons acquire an understanding of morbid obesity as a disease and an intimate knowledge of the numerous diseases and conditions induced or aggravated by morbid obesity.
They develop skills in patient education and selection and are committed to long-term patient management and follow-up. There is active collaboration with multiple patient care disciplines including nutrition, anesthesiology, cardiology, pulmonary medicine, orthopaedic surgery, diabetology, psychiatry, and rehabilitation medicine. Appropriate technical skills in the performance of bariatric surgical procedures are acquired.
A dedicated dietician is helpful to patients during their adjustment to postoperative dietary guidelines. Patients participate in a program of behavioral adjustment, exercise rehabilitation therapy, and, if available, a patient support group.
Indications and prerequisites
Not all persons who are obese or who consider themselves overweight are candidates for bariatric surgery. These procedures are not for cosmesis but for prevention of the pathologic consequences of morbid obesity. The patient must be committed to the appropriate work-up for the procedure and for continuing long-term postoperative medical management, and understand and be adequately prepared for the potential complications of the procedure. Screening of the patients to ensure appropriate selection is a critical responsibility of the surgeon and the supporting health care team.
Hospital facilities and personnel
In health care institutions recognized as accomplished in bariatric surgery, there is a demonstrated commitment to provide adequate facilities and equipment, as well as a properly trained and funded appropriate bariatric surgery support staff. Minimal standards in these areas are set by the institution and maintained under the direction of a qualified surgeon, in charge of a bariatric surgery management team. This team includes experienced surgeons and physicians, skilled nurses, specialty-educated nutritionists, experienced anesthesiologists, and, as needed, cardiologists, pulmonologists, rehabilitation therapists, and psychiatric staff.
The operating room environment required for performance of bariatric surgery has special operating room tables and ancillary equipment available to accommodate patients weighing up to 750 lbs. Appropriate bariatric retractors, staplers, and long instruments are available.
Anesthesia for bariatric surgical procedures is performed by individuals specially trained in this area and regularly assigned to bariatric procedures as a member of the bariatric surgery team. Specialized operating room staff familiar with the equipment, instruments, and procedures are identified as members of the bariatric surgery team. The staff of the recovery room and intensive care units is expert in the immediate postoperative care of the morbidly obese patient and their special needs, particularly for ventilatory support. The facilities conform to standards mandated by the Joint Commission on Accreditation of Health Care Organizations.
The preoperative assessment of morbidly obese patients may require special radiology equipment. The perioperative care of morbidly obese patients requires special beds, chairs, and commodes. Nursing personnel are trained and skilled in giving respiratory care, assisting with ambulation, and recognizing potential intravascular volume, cardiac, diabetic, and vascular problems.
Systematic long-term follow-up after obesity surgery is essential and includes dietary instruction, vitamin and mineral supplementation, exercise therapy, and, where feasible, patient support groups.
Morbid obesity is effectively treated with established surgical procedures, achieving substantial weight reduction and improved quality of life in the majority of patients with acceptable rates of mortality and morbidity. The optimal environment for achieving good outcomes includes a well-prepared and committed surgeon, an established and experienced bariatric surgical team of health professionals, appropriate institutional resources and equipment, and a system for patient evaluation and follow-up.
Recommendations for Facilities Performing Bariatric Surgery
Begg CB, Cramer LD, Hoskins WJ, Brennan MF. Impact of hospital volume on operative mortality for major cancer surgery. JAMA 1998;280:1747-51.
Brolin RL, Robertson LB, Kenler HA, Cody RP. Weight loss and dietary intake after vertical banded gastroplasty and Roux-en-Y gastric bypass. Ann Surg 1994; 220:782-90.
Campos CT, Buchwald H, Bourdages H. Gastric surgery for obesity. In: Digestive Tract Surgery: A Text & Atlas. Eds RH Bell, LF Rikkers, MW Mulholland,JB Lippincott Co, Philadelphia, PA. 1995; 281-294.
Centers for Disease Control and Prevention: Number and percentage of children and adolescents who were overweight by gender and race/ethnicity: United States NHANES III, 1988-1994. Morb Mortal Wkly Rep, 1997.
Choban PS, Onyejekwe J, Burge JC, Flancbaum L. A health status assessment of the impact of weight loss following Roux-en-Y gastric bypass for clinically severe obesity. J Am Coll Surg 1999;188:491-497.
Foley EF, Benotti PN, Borlase BC, et al. Impact of gastric restrictive surgery on hypertension in the morbidly obese. Am J Surg 1992; 163:294-7.
Health Implications of Obesity. NIH Consensus Development Conference Statement. Ann Int Med,103:1073-1077, 1985.
Kellum JM, DeMaria EJ, Sugerman HJ. The surgical treatment of morbid obesity. Curr Probl Surg 1998-1 35:795-858.
Lew EA, Garfinkel L: Variations in mortality by weight among 750,000 men and women. J Chronic Dis, 32:563-576, 1979.
McGinnis JM, Folge WH: Actual causes of death in the United States. JAMA, 1993;270:2207-2212.
Manheim LM, Sohn MW, Feinglass J, Ujiki M, Parker MA, Pearce WH. Hospital vascular surgery volume and procedure mortality rates in California, 1982-1994. J Vasc Surg 1998;28:45-56.
Naslund I, Agren G. Social and economic effects of bariatric surgery. Obes Surg 1991-1 1:137-40.
NIH conference: Gastrointestinal surgery for severe obesity. Consensus Development Conference Panel. Ann Intern Med, 115:956-961, 1991.
Pories WJ, Swanson MS, MacDonald KG, et al. Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus. Ann Surg 1995; 222:339-50; discussion 350-2.
Rosenbaum M, Leibel RL, Hirsch J: Obesity. N Engl J Med, 337:396, 1997.
Wolf AM, Colditz GA: Current estimates of the economic cost of obesity in the United States. Obes Res, 6:97-106, 1998.
Reprinted from Bulletin of the American College of Surgeons Vol.85, No. 9, September 2000
This statement and is Copyright © 1996-2000 by the American College of Surgeons, Chicago, IL 60611-3211
1. Pathophysiology of Morbid Obesity
2. Surgical Treatment for Severe Obesity:Preoperative Evaluation and Selection
Scott A. Shikora, M.D., F.A.C.S.
Surgical Director, Obesity Consult Center
Associate Professor of Surgery, Tufts University School of Medicine
Severe obesity is an ever-increasing problem in the western world. The health concerns and the high cost to society are well known. For this patient population, all of the current non-surgical treatment strategies have failed in achieving and sustaining sufficient weight loss. At present (and until there is a major breakthrough in obesity research), surgical strategies offer the only long-term solutions. The commonly performed procedures have never been safer nor more efficacious. The introduction of minimally invasive techniques has greatly increased the popularity of the field. However, the long-term success of any of these procedures is greatly dependent upon both the preoperative evaluation process and the continuity of care after the surgery. This article will briefly review the preoperative evaluation and patient selection process.
Defining and Classifying Obesity
Obesity is simply the state of excess body fat. However, the ability to accurately measure body composition is not readily available except at specialized centers. Therefore, simple, noninvasive measures are commonly employed. Although they generally are inaccurate for many patients, they remain acceptable surrogates. The simplest measure is to compare actual body weight to a standardized table such as the ideal (or desirable) body weight table. This table is based on insurance industry actuarial data but lists "desired" weights based on height and gender. Patients who weigh 20-30% more than their ideal body weight are considered obese. Another measure of obesity is the body mass index (BMI). BMI also categorizes weight as it relates to patient height. Currently overweight is defined as a BMI of 25-29.9 kg/m2 and obesity defined as a BMI of 30 kg/m2 or greater. Morbid or extreme obesity is generally defined as a BMI of 40 kg/m2 or greater. Although both percent of ideal body weight and BMI suffer from inaccuracies, particularly at the extremes of body size and shape, they do generally correlate with body fat.
Currently it is estimated that over 30% of people in the U.S are overweight, over 20% can be defined as obese, and as many as 6 million Americans have extreme obesity.
There is now reasonable unanimity in the medical literature that obesity is associated with risk for serious health hazards and a shortened life expectancy. There are a multitude of obesity-related comorbidities that have been well described (table). The risk of death from comorbid conditions increases exponentially as weight increases. Further, obesity exerts a less quantifiable but very substantial effect on quality of life.
Despite the advances in peri-operative care, surgery remains an invasive and potentially life-threatening option for an otherwise high risk patient population. Therefore, it should be reserved only for patients where the surgical risks are outweighed by the potential benefits. Currently few studies have evaluated the cost-effectiveness of surgical verses non-operative therapies. One study, by Martin and colleagues, confirmed that surgery was a less costly treatment option for patients with extreme obesity and had a significantly greater success rate. Therefore, until further analysis proves otherwise, surgery should be considered an acceptable option for the small subset of extremely obese patients. Current National Institute of Health Guidelines support reserving surgery for patients who meet strict criteria. First and foremost, patients must meet or surpass a weight threshold. Potential surgical patients must weigh more than 200% of their ideal body weight (BMI>40 kg/m2), or have a BMI>35 and suffer from obesity-associated comorbidities that would be expected to improve or even resolve with surgical weight loss. These conditions include diabetes, hypertension, and sleep apnea. In addition, all potential candidates should have demonstrated repeated failure to control weight by medical means including supervised dietary programs. Although most medical conditions do not disqualify patients from surgical consideration, behavioral issues might. Since behavior modification is necessary for long term success following surgery, patients with significant psychiatric disorders, mental retardation, substance abuse, or self-destructive behavior will rarely be considered.
Traditionally, most surgeons restricted surgery only to patients who were older than 18 and less than 50 years of age. This was based on some of the earlier studies that demonstrated higher operative morbidity and mortality in older patients. Better perioperative patient management has enabled many surgeons to offer surgery to older patients. Currently, most bariatric programs will consider patients who are in their sixth decade of life, assuming they are otherwise acceptable candidates. However, they need to demonstrate a reasonable duration and quality of life and real expectations that the surgery and resultant weight loss will enhance it. Our program offers surgery to otherwise good candidates who are up to 70 years of age. We have found no greater morbidity or mortality in this population. In addition, weight loss and quality of life were similar to younger patients.
The other end of the age spectrum is still controversial. Extremely obese adolescent patients will usually be physically healthy and pose minimal operative risk. However, they may not have reached the level of maturity necessary to succeed with the drastic life changes. In that setting, a good surgical outcome may not translate into a good long-term result. Under certain circumstances, younger patients should be considered for surgery, particularly if they have the appropriate behavioral support structures. Many have demonstrated excellent weight loss and improvement in quality of life.
Obesity is a complex condition that may be caused or influenced by numerous factors such as genetics, environment, social issues, behavioral factors, etc. In addition, many obese patients develop dysfunctional behavior as a consequence of their obesity. Certain eating and lifestyle issues may not be conducive to a good outcome after surgery. Therefore, a comprehensive psychological evaluation is essential. A complete history of current living conditions, life stresses, family relationships, and childhood is obtained. As previously described, patients with abusive or self-destructive habits are usually eliminated from consideration. Similarly, patients with significant psychiatric disorders such as psychosis or schizophrenia, or those that are afflicted with severe mental retardation will also be considered inappropriate for surgery. The behavioral evaluation is also an opportunity for patient education and preparation. Potential surgical patients need to make significant lifestyle and behavioral changes to succeed after surgery. Preoperative instruction and counseling can facilitate these dramatic changes. Liberal use of patient support groups can also be helpful for patient candidates to establish role models from those who have done well after surgery. Groups also reinforce a sense of belonging for many patients who believe that their plight is unique. Patients initially rejected from surgical consideration because of behavioral issues can be reevaluated for surgery if they respond favorably to psychiatric or psychological therapy.
As previously described, there are a number of diseases associated with obesity. Unfortunately, these conditions are often under appreciated. This is seen with many diseases such as diabetes and hypertension, but particularly common with obstructive sleep apnea. It is therefore mandatory to carefully evaluate each patient prior to surgery. Treatment of these conditions may improve perioperative results. This evaluation should include a thorough history. Patients are specifically asked about chest pain, shortness or breath, gastrointestinal reflux, medication use, activity level, sleep patterns, bowel function, previous hospitalizations, and past surgeries. A comprehensive physical examination is also performed. Pre-operative screening should include routine blood work, liver function tests, thyroid screening, arterial blood gases, hemoglobin Hc1, and pregnancy testing for women of childbearing age. Pulmonary function testing, electrocardiograms, gallbladder ultrasonography, and standard chest x-rays are performed on all of our patients. In addition, other testing such as sleep studies, cardiac stress testing, etc, are obtained as indicated from the history and physical examination. Specialty consults such as cardiology, endocrinology, and pulmonary may also be required prior to surgery. Medical comorbidity rarely will disqualify patients for surgery unless they are considered prohibitive and the predictive operative mortality significant enough to pose an unacceptable risk. However, fully evaluating each patient preoperatively to elucidate the extent of the comorbidity may alter the surgical and anesthetic management of the patient in the perioperative period and/or the postoperative management.
Surgical evaluation is also a two-phase process. It is designed to both educate the patient in regard to the surgical procedure and the potential risks. Patients should recognize that the surgery could have serious and occasionally life-threatening complications. Patients need to weigh their surgical risks against the risks of untreated obesity. Patients need to also understand the anatomical changes which they are consenting for and their ramifications. These changes will reduce gastric capacity, alter gastrointestinal function, necessitate dietary restrictions, impair vitamin absorption, and cause potential long-term nutritional consequences. Patients unable to grasp these issues may not make good operative candidates.
Surgical evaluation should also include a thorough history and physical. Gastrointestinal disorders such as colitis, inflammatory bowel disease, abdominal pain, guaiac positivity, gallstones, peptic ulcer disease, abnormal bowel habits, etc, should be identified and may generate additional evaluation or alter operative technique. Patients should also be screened for previous abdominal surgeries and ventral hernias. Finally, many patients may have undergone a gastrointestinal procedure weight loss in the past. It is critical to determine the type of procedure performed, whether it is intact or has been disrupted. Acquiring the operative report and obtaining an upper gastrointestinal contrast x-ray series is necessary as a road map.
As we enter the new millennium, severe obesity remains an incurable disease. The consequences and the cost to society are significant. Although the etiologies of obesity are becoming more and more clear, for the extremely obese, non-surgical treatments are still inadequate for achieving significant or sustained weight loss. Surgical approaches have evolved into safe and effective options. Newer technologies such as laparoscopy should further advance the field. For appropriately selected patients, surgery can achieve the weight loss necessary to improve or prevent the development of significant medical conditions and improve quality of life. Unfortunately, dietary indiscretion and maladaptive eating behavior can result in weight loss failure despite an excellent surgical result. Therefore, the preoperative evaluation process which includes comprehensive evaluation and education is a cornerstone to long-lasting success.
Table. The Obesity-Associated Medical Conditions
Coronary artery disease Hypertension
Cardiomyopathy Cerebrovascular disease
Diabetes mellitus Endocrine abnormalities
Infertility Hepatobiliary disease
Degenerative joint disease Chronic back pain
Respiratory abnormalities Gallstones
Hepatic steatosis Gastroesophageal reflux
3. OPERATIVE PRINCIPLES: SETTING UP A BARIATRIC PROGRAM
The successful performance of bariatric surgery is only accomplished if the all the necessary elements of a comprehensive program in bariatic surgery are available at the facility or institution providing such care. A list of these elements of the program is summarized below.
There is no substitute for adequate preparation of the surgeon. This includes a significant experience in the performance of bariatric surgery under guidance or with the assistance of another experienced bariatric surgeon. Attending a weekend course and observing another surgeon perform bariatric surgery, while an appropriate starting point for surgeon preparation, is not adequate. The American Society for Bariatric Surgery currently offers preceptorships to members, which involve the attendance of a basic didactic course, followed by a proctored experience in a minimum number of bariatric cases. Experts in the field are divided as to whether this is an adequate experience for the novice bariatric surgeon. Certainly anything less is insufficient. Most experts agree a mini-fellowship of up to three months would provide superior and likely adequate preparation, but currently the mechanism for providing such fellowships on a scale appropriate to the demand does not exist.
In 2001, the surgeon wishing to set up a bariatric program must, in order to meet patient demand, not only prepare himself or herself to perform open bariatric surgery, but also plan to gain the necessary skills to offer laparoscopic versions of their bariatric operations. The current trend in bariatric surgery dictates that patients will soon be much more willing to accept, and be benefitted by, using a laparoscopic approach whenever feasible. Therefore, while many bariatric surgeons still have enormously successful programs using only open procedures, it is recommended that the surgeon setting up a program at this time strongly consider the need to obtain the appropriate advanced laparoscopic skills to be able to offer a laparoscopic approach to the performance of bariatric surgery. Such advanced laparoscopic skills may be in large part obtained by the performance of other advanced laparoscopic gastrointestinal operations, such as colon resection or antireflux surgery. However, the difficulty of laparoscopic bariatric surgery again places the burden on the surgeon of the need to acquire specific additional advanced laparoscopic training from a skilled laparoscopic bariatric surgeon. The same duration and type of proctored experience as mentioned above may suffice for the surgeon to optain an adequate initial experience in laparoscopic bariatric surgery. A surgeon skilled in open bariatric surgery, or a surgeon skilled in advanced laparoscopic surgery, will require a shorter and less intense training period than one with neither skills.
Once initial adequate training is obtained by the surgeon, he or she must remember that the need for additional collegial consultation and support will exist for quite some time during the performance of bariatric surgery. The surgeon should be prepared to seek such consultation whenever clinical problems arise which are unfamiliar or difficult to address.
One final aspect of surgeon preparation must be stressed. The surgeon must be mentally and physically prepared to provide ongoing supportive care, on a personal basis, for a group of patients who have enormous needs and demands. The practice of bariatric surgery is demanding in this respect, yet provides the surgeon with an equally rewarding return for such efforts.
While surgeon preparation is paramount, no person is an island, and certainly not in the provision of optimal surgical care of the bariatric patient. Having a skilled and knowledgeable operative team to assist the surgeon is paramount to success. Even the most skilled surgeon will meet with ongoing frustration if such personnel do not exist.
A skilled first assistant is of utmost importance, especially in the performance of laparoscopic bariatric surgery. The more skilled the assistant, the more smoothly and quickly the operation can be performed. The surgeon who undertakes bariatric, and particularly laparoscopic bariatric surgery without a skilled first assistant faces a difficult task to successfully complete the operation in a safe and timely fashion.
It is just as important to have skilled nursing assistance during the performance of bariatric surgery. The scrub nurse should be totally familiar with the equipment and instruments involved, including any laparoscopic equipment and instruments. Intraoperative delays and potentially complications will result if the scrub nurse is not adequately trained and prepared.
The circulating nurse needs to be aware of the special needs of the bariatric patient, especially those of postioning, safe support for intraoperative maneuvering such as reverse Trendelenberg positioning, and medications indicated preoperatively. In addition, she or he needs to be as knowlegeable about the instruments and equipment involved in the case as the scrub nurse.
The anesthesiologist and his or her team is a critical component in the provision of a safe operative experience for the bariatric patient. The anesthesiologist should be skilled and experienced in the care of severely obese patients. This includes special competence in airway maintenance, intravenous access, fluid administration, medication dosages (including muscle relaxants), and ventilatory requirements of this patient population. If the operation is to be performed laparoscopically, the additional needs of ventilator management, pH monitoring, and cardiopulmonary supportive measures needed during laparoscopy must be understood. Finally, the surgeon and the anesthesiologist must maintain good preoperative and intraoperative communication to be sure each understands the others concerns and needs, and to facilitate intraoperative maneuvers such as passing NG tubes and dilators.
The surgeon must secure the appropriate operative equipment to perform the bariatric procedure planned. This includes having the appropriate laparoscopic videotechnology and equipment if this approach is to be used. There is no substitute for inadequate equipment, and the surgeon and his or her operative team should be certain that the equipment needed for the procedure is present and in good working order before proceeding with an operation.
Once the operation is completed, the bariatric patient's postoperative care must be administered by personnel adequately experienced and trained for the peculiar needs of this patient population. The nursing staff must be aware of the need for monitoring vital signs, and the concern which aberrancies from baseline values should create. The special needs of fluid administration, medication dosages, deep venous thrombosis prophylaxis, early ambulation, and wound and skin care should all be well known to the nursing staff caring for the postoperative bariatric patient. Other special requirements such as CPAP administration, physical therapy needs, special beds, special stretchers, special wheelchairs, and other special equipment should be ordered and available for the patient's needs.
The severely obese patient population will require, more often than the average hosptial patient population, the consultation of special support services provided by the hospital, especially physical therapy and "lift teams".
If the patient has severe end-organ disease of one particular system, the surgeon is well advised to have the appropriate consultants available to assist in the patient's care. Optimally they will have seen and evaluated the patient before surgery as well, and maximized preoperative medical treatment.
Dietitian consultation is imperative in the postoperative period. Often the dietitian will be the same person who covers outpatient visits and requirements, but if not then the hospital dietitian must be totally familiar with the recommended postoperative diet and progression of oral intake appropriate to the particular bariatric operation.
The hospital where the bariatric program is to be set up must be willing to provide the above personnel and support, both in terms of the operative and postoperative personnel and their training. It is essential that the surgeon have appropriate support guaranteed from the hospital administration before embarking on a program in bariatric surgery.
There is no more key person in the components of a successful bariatric surgery program than the nurse coordinator. She or he is the surgeon's right arm in terms of caring for the bariatric patient population. Responsibilities of the nurse coordinator include overseeing or performing preoperative teaching, providing first contact assistance for preoperative or postoperative clinical questions and issues, and coordinating the appropriate preoperative and postoperative care from consultants and assistants to the surgeon. The nurse coordinator facilitates getting the patient through the necessary preoperative steps in preparing for surgery, and overseeing the postoperative followup to be certain patients do not "fall through the cracks" in the system. A busy bariatric surgeon may often need more than one nurse coordinator, should patient demands and load require it.
Bariatric patients require the dedicated support of a dietitian well versed in the particular needs of this patient population. Dietary assessment is an essential component of the preoperative evaluation of the patient. Postoperative ongoing consultation and evaluation by the knowledgeable dietitian is also essential to provide optimal care for the bariatric patient, and to eliminate or minimize problems of poor protein intake, vitamin or mineral deficiencies, and other nutrition-related problems peculiar to the particular operation performed. Malabsorptive operations have a known incidence of significant metabolic and nutritional problems, and for patients undergoing such procedures, thorough preoperative dietitian teaching and consultation and postoperative careful followup is mandatory.
The surgeon contemplating beginning a bariatric program must be certain that his or her secretary is prepared and willing to undertake the unbelievably large amount of work this will entail. The average bariatric patient requires two to three times the time expenditure preoperatively by the office secretary and/or manager than the typical general surgery patient. There is also a higher incidence of postoperative calls to the office, and the time demands inherent in long term followup of each patient. In my general surgery practice, where operations for bariatric patients represent 25% of the annual operative case load, over 50% of my secretary's time is spent on issues for these patients. The office secretary must have considerable amounts of patience to deal with the demands of the bariatric patients. Such demands are often not directed by the patient at the surgeon, but instead at the office personnel and nurse coordinator. Patient counseling on the first visit may help to diminish what is otherwise a continuous volume of phone calls regarding issues of insurance approval, surgery date scheduling, clinic visits, and so forth.
In any bariatric practice, the establishment of some form of patient data base for monitoring results and long term outcomes is essential for providing optimal care. Otherwise, the surgeon has no objective assessment of the outcomes of surgery. Management of such a database can be by the surgeon, by trained office personnel, the nurse coordinator, by a special database manager, or by a combination of the above.
The clinic and/or office where patients are seen for outpatient evaluation and postoperative care must be specially equipped to handle the needs of the bariatric patient. Special equipment needs include benches or couches as opposed to chairs for seating, extra wide wheelchairs, examining tables which are designed for the severely obese patient, appropriate scales for weighing patients, and special wide blood pressure cuffs.
A patient support group, optimally run and administered by interested (and usually successfully treated postoperative) patients, is a wonderful and highly recommended element of any bariatric surgery program. The group should provide information to prospective patients about the experiences of undergoing bariatric surgery from a patient perspective. Mutual support and encouragement among members encountering postoperative concerns and difficulties is also a key role of the group. While the surgeon is urged to recruit patients to the group and provide necessary support in terms of facilities and mailings, the best support groups are those run by the patients themselves.
While there is some debate among bariatric surgeons as to the value of preoperative psychiatric screening, it has been our experience that a psychiatrist interested in and dedicated to screening bariatric patients is a valuable part of the program. The psychiatrist should optimally screen all patients who are candidates for surgery. The surgeon will become quite surprised and educated at the significant incidence of depression, sexual and physical abuse, and other problems in the bariatric patient population, problems which may not surface in an initial screening history and physical done in the clinic. The compliance with recommendations for short-term treatment of depression is often a good indicator as to the patient's true motivation toward having a successful outcome from their bariatric operation.
The primary care physician will by definition be essential in the appropriate management of the severely obese patient undergoing bariatric surgery. Good communication between the surgeon and the primary care physician is essential in the perioperative as well as the postoperative period. The surgeon must preoperatively confirm that the prospective patient has a firm and ongoing relationship with a primary care physician, since many patients will self-refer themselves on the basis of contact with other patients. Such a relationship is mandatory in our practice before surgery is offered. Documentation of preoperative unsuccessful medically supervised diet programs is usually a requirement of most insurance companies for approval of surgery, and such documentation must be provided by the primary care physician. The surgeon must provide the primary care physician with the appropriate information regarding problems often seen in the bariatric patient population postoperatively, be responsive to any concerns raised by the primary care physician during followup, and urge the primary care physician to call for any concerns which may be related to the operative procedure or its sequelae. Often the worst results occur postoperatively when the patient develops a problem which the bariatric surgeon could treat appropriately and effectively, but the surgeon is not informed and the patient goes on to receive inappropriate care by well-meaning health care providers who are ignorant of the appropriate treatment.
1. Schirmer BD. Laparoscopic Bariatric Surgery Surg Clin N America 2000; 80:1253-67.
2. Brolin RE. Critical analysis of weight loss and quality of data. Am J Clin Nutr 1992; 55a(2 Suppl):577S-581S.
3. Rabner JG, Greenstein RJ. Obesity surgery: expectation and reality. Int J Obes 1991; 15:841-5.
4. NHLBI Obesity Education Initiative Expert Panel on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. Clinical Guidelines on the identification, evaluation, and treatment of overweight and obesity in adults. National Institutes of Health, June 1998.
5. Shikora SA. Surgical treatment for severe obesity. The state-of-the-art for the new millenium. Nutr Clin Pract 2000; 15:13-22.
6. Gastrointestinal surgery for severe obesity. Consensus development conference panel. Ann Int Med 1991; 115:956-61.
Morbid obesity was one of the most frequent relative contraindications to performing laparoscopic procedures. The irony is that in the present day laparoscopy has quickly replaced open surgery as a primary approach to the surgical management of obesity. There are a number of hurdles that must be overcome in order to have a good outcome when approaching these patients. Furthermore an understanding of some of the heightened physiologic sequelae to carbon dioxide pneumoperitoneum is important to facilitate the perioperative care in the obese patient. This discussion centers on overcoming some of the anatomic obstacles that are encountered in the obese patient as well as some of the physiologic derangements that must be taken into consideration.
Access: This can be a particularly challenging portion of the case. A number of general surgeons use the traditional open Hasson technique for initial access. This is particularly true in the patient who has undergone previous surgery. In the obese patient the subcutaneous fat may be several centimeters deep. The incision that may be required may be substantial just to identify the fascia. Placement of sutures in these patients maybe difficult without a generous incision. This problem can be overcome in two ways. One is through the use of the Veress needle. Initially this is thought of as a daunting procedure for some though it is associated with a very low and acceptable complication rate. The left upper quadrant in the midclavicular line is a reasonable place to insert the needle. One important consideration is that a 150mm needle be used rather than the traditional 120mm needle. A suture can be placed at the level of the skin for anterior retraction of the abdominal wall. Opening pressures may be as high as 12 to 15 mmHg. An advantage of the needle technique is that a 5mm port may then be inserted. This obviates use of an unnecessarily large port that may increase the risk of hernia formation and increase incisional pain. In our series of just under 600 patients we have seen one complication related to use of the Veress needle. There are ports that are available (Visiport, USSC Norwalk CT) that allow directed port placement with the laparoscope as an inner cannula. Both of these are reasonable options.
Exposure: The most important component of this is careful port placement. For the gastric bypass the laparoscope should not be placed more than 2 to 3 cm inferior to the inferior to the inferior portion of the falciform ligament. It is important to use a steeply angled scope 30 degrees at a minimum though we routinely use a 45-degree scope. There are now longer scopes that are available that allow the scope to be placed more inferiorly. The advantage of this is that this facilitates the jejunojenunostomy. Stable liver retraction is critical during the procedure and this task should not be delegated to an assistant. The are a variety of table mounted devices available. Occasionally it is necessary to use two liver retractors in the case of a giant lateral segment of the liver. This retractor can be placed in the subxiphoid position or in the right lower quadrant. In some cases it is simply safer to convert to open than to continue laparoscopically. There are a number of miscellaneous things that should be kept in mind. It is useful to have available a high flow insufflator capable of producing flows of 30 liters per minute. If this is not available then it is advisable to have 2 insufflators for the case.
Stapling techniques: Suffice it to note that the principles are the same regardless of the patients' body habitus. We have observed decreased bleeding from the staple lines from using staple cartridges that are of a lower height. To divide the stomach we use the 3.5mm staples. Division of the small bowel is carried out using the 2.5mm staple cartridges. We use a stapled end to side technique to perform the gastrojejunostomy. This anastomosis should be performed over a narrow bougie. We have used a flexible endoscope with a diameter of 1 cm as the bougie. There are a number of advantages to this. The two principle advantages are the ability to control the tip during passage and second that placement facilitates testing of the anastomosis with distension.
Port closure: One of the reported advantages of the laparoscope over conventional bariatric surgery is elimination of the large abdominal wound and its complications. Certainly the risk of dehiscence exists in these cases. The risk of hernia postoperatively varies between 10 and 22%. It is interesting to note that in cases of laparoscopic reexploration there is a remarkable incidence of sub clinical fascial weakness in these patients. Though there are emerging case series following laparoscopic gastric bypass surgery suggesting that the fascial defects of these ports need not be closed we still emphasize the closure. The rationale being that this is a relatively easy procedure to perform using the variety of port closure devices that exist on the market. Further there are no long term follow-up studies yet to prove that there is no need to close port sites that are 12mm and smaller.
Physiology of pneumoperitoneum:
The increased intraabdominal pressure that is present in the morbidly obese only accentuates the deleterious effects of carbon dioxide pneumoperitoneum in these patients. The effect of the carbon dioxide pneumoperitoneum can be made worse by the duration of the pneumoperitoneum and the absolute pressure at which this is delivered. The large subcutaneous space in these patients creates a larger space over which the carbon dioxide gas can diffuse. Generally the effects of hypercarbia are well tolerated. It is important to note that the measured end tidal carbon dioxide levels underestimate those obtained directly from an arterial blood gas measurement. Measures to lower the end tidal carbon dioxide levels include increasing the respiratory rate and the tidal volume. This can be difficult to accomplish in patients with acquired pulmonary disease as the dead space may be increased. Patients with fixed cardiac output should be converted if levels of end tidal carbon dioxide become significant.
An interesting situation arises in the patient who has preoperative renal insufficiency or who has only one kidney. The basic science data that we have available suggests that there is a decrease in the renal blood blow related to the level of pneumoperitoneum. There certainly have been reported instances of postoperative renal insufficiency in patients with super morbid obesity requiring prolonged pneumoperitoneum. There is some evidence from an ongoing randomized prospective study to suggest that the urine output in the perioperative period is no less in the laparoscopic patients compared to the open gastric bypass patients. In short reduction of port site leakage with decrease in subcutaneous emphysema, use of lower insufflation pressures when feasible and reduced operative times may make intraoperative management of complex patients simpler.
5. Essentials of Laparoscopic Vertical Banded Gastroplasty
Mercer University School Of Medicine, Atlanta Georgia
Surgery is an option for patients 100 pounds overweight , or whose BMI is 40 or greater due to the greatly increased risk of health problems and early death associated with this level of clinically severe obesity. In addition , patients with a BMI between 35 and 40 with an associated co-morbidity may also be candidates for surgery.
Examples of obesity related health problems :
Surgical operations for morbid obesity work by either restriction or malabsorbtion , or a combination of the two. The VBG is purely a restrictive procedure which limits the intake of food and produces early satiety. Pouch size and stabilization of the outlet are therefore crucial technical points to maximize success.
WHY CONSIDER A LAPAROSCOPIC APPROACH ?
Open surgery for bariatric surgery is associated with around a 30% wound complication rate ; with incisional hernias , infections and seromas which delay recovery and require futher treatment or surgery.Some patients favor the VBG because it is less invasive and has a shorten recovery compared to gastric bypass or purely malabsorptive procedures.The laparoscopic approach offers a minimally invasive approach associated with less pain and scarring , a reduction in hospitalization and recovery time , and greatly reduces wound complications.
Laproscopic procedures for morbid obesity should employ the same principles as open surgery. The technique must be precise and should vary from the open procedure only in the size of the skin incision. Not all patients are a candidate for this approach and they require special surgical expertise to reduce operating time and complications.The American Society for Bariatric Surgery recommends that laparoscopic obesity operations should be performed only by surgeons with advanced laparoscopic skills , who have experience and training in open bariatric procedures , and who understand the complexities of surgical treatment of morbid obesity. No one should perform this procedure laparoscopically , unless they have become proficient in the open technique.
Due to the obesity patients greater girth , 45 cm graspers , needle drivers , and scissors are necessary.Most manufactures also make a longer version of their 5mm and 12 mm trocars . A copy of my instrument set is enclosed. A 45 degree scope is mandatory for adequate visualization , with a high optics camera system. Some surgeons find dual insufflators to be helpful . An open set up needs to be readily available if a conversion is necessary. A stapling product which is versatile and fits through a 12 mm tocar is required for a linear technique , with a circular stapler for the classical approach.
A diagram of trocar location is enclosed . We utilize 6 trocars , with four 5 mm and two 12 mm ports as demonstrated. The camera port is a 12 mm site 15 cm below the xiphoid just to the left of the midline . If you place your port at the umbilicus it will not be long enough to view the upper stomach and angle of HIS. The other 12 mm port is located in the left upper quadrant , just below the costal margin .
SURGICAL TECHNIQUE FOR LAPAROSCOPIC VBG :
There are two principle approaches utilized for a laparoscopic VBG . The classical approach employs a circular stapler to form an opening 5 cm below the angle of HIS near the lessor curve of the stomach . A linear stapler is inserted via the circular opening along side a bougie and fired upward thru the angle of HIS , to divide the pouch from the fundus . A five by one and a half cm band is then placed around the distal pouch to stabilize the stoma.A diagram of this technique is enclosed.
The second technique, which is demonstrated in the video, employs wedging a five by five cm segment of stomach as demonstrated in the diagram to create a 20 cc pouch which is then banded with a five cm band. This video is available for purchase from the SAGES video library.
The principles for performing a VBG are (1) construction of a proximal gastric pouch of 30 cc or less , which is measurable and reproducible ( 2) a outlet stoma stabilized with a band ( most commonly 12mm) . Variation is seen between different surgeons as to the best means to accomplish the technique . Controversy also exists over stoma size and the band material , with a variety of prosthetics such as polypropylene , gore-tex , or a silastic ring being employed today. The debate over whether to divide the pouch , or staple in continuity is also unresolved with proponents for each approach .
The results of our 55 patients who under went a totally laparoscopic VBG ,utilizing a linear wedge technique as demonstrated in the video are as follows :
INTRAOP COMPLICATIONS : 1 ( 2.2% ) STAPLED NG TUBE
2-persistant vomiting requiring dilatation
% EXCESS WEIGHT LOSS : ( n=55 )
6 MONTHS ---------- 41 % ( range 26-73 % )
12 MONTHS --------- 63 % ( range 42- 104 % )
ADVANTAGES OF RESTRICTIVE BARIATRIC SURGERY ( VBG ) :
The principle advantages of the VBG are it is simpler to perform than gastric bypass and preserves the normal gastro-intestinal route for food . Micronutrients such as iron calcium and B vitamins are more easily maintained. The distal stomach is also accessible via endoscopy . Hospitalization , recovery time and expense is reduced.
The principle reason the VBG has fallen out of favor by most bariatric surgeons is it's documented history of less weight loss compared to gastric bypass and a regain of weight long term . This is due to its inability to restrict intake of high calorie liquids and sweets . Pouch stretching can also occur with overeating and lead to a failure of weight loss. A high percentage of patients will subsequently require conversion to a gastric bypass to achieve adequate weight loss. This makes the procedure inappropriate for sweet eaters and snackers who consume small amounts continuously through out the day.
Long term complications can occur secondary to the band , with the most common being a reduction in outlet size due to scar tissue buildup , resulting in recurrent vomiting and requiring either dilatation or revision. Band erosion can also occur , which may require revision or failure to lose weight . Band disruption is also possible leading to failure .
Staple line leaks can also occur in 0.5 to 2 % of patients with potentially lethal outcomes and must be aggressively investigated and treated early. Staple line disruption may occur in undivided procedures in up to 15 % of patients and will result in a failure to maintain weight loss .
A comprehensive list of reported complications with bariatric procedures is enclosed for review. The incidence of mortality after VBG is ~ 0.5 % .
1. Mason EE.Gastric surgery for morbid obesity . Surg Clin North Am 72:501 , 1992.
2. Deitel M. Overview of operations for morbid obesity. World J Surg 22:913 , 1998.
3. Mason EE , Doherty C , Cullen JJ , et al. Vertical gastroplasty: evolution of vertical banded gastroplasty.World J Surg 22:919 , 1998.
4. Lonroth H, Dalenback J , Haglind E , et al. Vertical banded gastroplasty by laparoscopic technique in the treatment of morbid obesity. Surg Laparosc Endosc 6: 102, 1996.
5. Fox SR, Oh KH, Fox K . Vertical banded gastroplasty and distal gastric bypass as primary procedures : a comparison. Obes Surg 6 :421 , 1996.
6. Capella JF , Capella RF. The weight reduction operation of choice : vertical banded gastroplasty or gastric bypass? Am j Surg 171:74, 1996.
7. Azagra JS, Goergen M, Ansay J, et al. Laparoscopic gastric reduction surgery. Surg Endosc 13:555,1999.
6.Laparoscopic Roux-en-Y Gastric Bypass Using a Stapled EEA vs GIA Technique for the
Gastrojejunal Anastomosis
S. Ikramuddin M.D., R Ramanathan M.D., W Gourash, CRNP, PR Schauer M.D.
7. LAPAROSCOPIC VERTICAL Banded Gastroplasty WITH Roux-en-y Gastric Bypass for Morbid Obesity
Aureo L. De Paula, MD and Kiyoshi Hashiba, MD.
Department of Surgery, Instituto ING, Goiânia, Goiás, Brazil
A number of surgical procedures for the treatment of morbid obesity have already been described. The three most frequently used bariatric surgeries are the vertical banded gastroplasty [1], the Roux-en-Y gastric bypass [2] and the adjustable gastric banding [3]. Despite the good results achieved after short-term follow-up of vertical banded gastroplasty and adjustable gastric banding [4,5], the long-term follow-up of these techniques has demonstrated significant weight gain and some specific complications [6,7]. Roux-en-Y gastric bypass has achieved better rates of weight loss in short as well as in long-term follow-up [8,9]. Nevertheless, this procedure may result in micronutrient deficiencies, especially iron, B12, folate and calcium [10]. Despite the efficacy and relative safety of these techniques, significant rates of complication directly related to the surgical approach such as incisional hernias and wound infection can be observed [11].
Laparoscopic surgery has revolutionized the treatment of a number of digestive surgical diseases and has evolved to be a safe, reliable and a highly effective operation. It has been demonstrated that the technique of open surgery could be reproduced with lower morbidity and mortality rates, shorter hospital stay and quicker resumption of daily activities. The purpose of this study is to evaluate the clinical results of the association of vertical banded gastroplasty (VBG) to Roux-en-Y gastric bypass (RYGBP), Fobi-Capella [12,13] procedure, performed by the laparoscopic approach (LVBG-RYGBP).
From November 1997 to July 2000, 156 patients underwent laparoscopic vertical banded gastroplasty with Roux-en-Y gastric bypass according to the criteria of the 1991 "NIH Consensus Development Panel" of bariatric surgery [14]. Patients with previous history of esophageal/gastric surgery, BMI greater than 85, age under 16 and over 65 and severe coagulation disorder were excluded. Ninety-six patients were female and sixty were male. Mean age was 37.8 (range16-65). Mean BMI was 49.1 kg/m2 (range 33.5 B 83 kg/m2). Fifty-seven (36.5%) patients were considered superobese, with BMI greater than 50 kg/m2. Associated diseases included: diabetes (8.3%), hypertension (38.4%), sleep apnea (7%), dislipidemia (27%), cholelithiasis (11.5%), obesity-hypoventilation syndrome (4.5%), arthritis (31%), GERD (14%) and asthma (3.2%).
The patients were evaluated slowly, over a period of time, usually 1 to 2 months in order to be sure of the adequate education of the patient and family about the operation and its consequences. Preoperative exams included cardiovascular, pulmonary and endocrine tests, upper GI endoscopy and abdominal ultrasound. Nutritional and psychological evaluations were obtained in the majority of the patients. Intensive breathing exercises and thromboembolic prophylaxis were assured.
The pneumoperitonium was established with a Veres needle adjacent to the left costal margin.
One 10 mm, two 5 mm and two 12 mm trocars were used. The first step was the creation of a Roux-en-Y loop. The jejunum was divided 50 cm from the ligament of Treitz with a linear stapler. The enteroenterostomy was performed a 100 to 150 cm distally. This side-to-side anastomosis was done using a linear stapler. An oversewn running prolene suture was performed to closure the jejunal holes and also at the staple line (anterior and posterior). The mesenteric gap was closed to prevent internal herniation. Next, an opening was made through the mesocolon and the lesser sac. The efferent limb of the Roux-en-Y was then brought up, retrogastric. The dissection of the greater curvature is done above the most cranial short gastric vessel up to the angle of Hiss. The delimitation of the proximal gastric pouch was done along the lesser curvature with a vertical orientation, just left to the gastroesophageal (GE) junction down to a point at 7 cm. The width of the gastric pouch was calibrated with an internal dilator of 1.2 cm. The dissection of the lesser curvature was performed adjacent to the gastric wall, as small as possible, 7 to 8 cm inferior to the GE junction, in order to open lesser sac. The division of the stomach was done with a linear stapler. Both the gastric pouch and the bypassed stomach were oversewn with a running absorbable suture. A Silastic ring band, 6.2 cm long, was placed around the pouch loosely at a point about 5.0 cm from the GE junction. The efferent limb was used as a serosal patch to cover the stapled edge of the gastric pouch, from the GE junction down to the level of the anastomosis. A hand-sewn gastroenterostomy, end to side, 2 cm long, was made distal to the band. Following the completion of the anastomosis, the anesthesiologist instilled methylene blue-colored solution in order to verify possible leaks from both the gastric staple line and anastomosis. The mesocolon opening was closed with interrupted sutures. The abdominal cavity was drained routinely.
Postoperative care and Follow-up
A very small percentage of patients needed to spend the first night at an intensive care unit. Patients were kept on nothing-by-mouth until they pass flatus, usually 24 to 48 h following the operation. Ambulation and active physiotherapy was initiated in the first postoperative day. Patients underwent an upper gastrointestinal series prior to resumption of diet and discharge. They were instructed to continue with low-molecular weight heparin until the 10th postoperative day. Full fluids were maintained for 2 weeks and then cautiously progressed to full diet by the end of 4 to 6 weeks. They were seen postoperatively at 1 week, 1 month, 3 months, 6 months, 9 months, 1 year, 1.5 years, 2 years, and then yearly thereafter.
Mean operative time was 190min (range 150min - 7h). Two patients were converted to open surgery. Associated procedures included 18 cholecystectomies, 14 crural closure and 1 umbilical hernioplasty. Intraoperative complications included 3 malfunctioning of the linear stapler, with wide opening of the gastric lumen and 1 gastric perforation during the placement of the silastic ring.
Early postoperative complications included wound infection (1.4%), leaks (1.4%), pneumonia (1.4%), digestive bleeding (2.8%) and perforated jejunal ulcer (0.7%). Median hospital stay was 3.1 days (range 2-25 days). Postoperative follow-up ranged from 1 to 33 months. Late postoperative complications included 16 marginal ulcerations, 1 anastomotic stricture treated endoscopically and 1 band erosion.
Mean excess weight loss was 51% in 6 months, 73.4% in 12 months, 78,2% in 18 months and 76.6% in 33 months. All patients with GERD, sleep apnea, cholelithiasis, umbilical hernia and obesity-hypoventilation syndrome had resolution of their medical problems. Hypertension, diabetes and asthma had partial improvement. There was a significant improvement of the quality of life of all patients
according to the Moorehead-Ardelt quality of life questionnaire.
Technical feasibility of different laparoscopic procedures has been confirmed throughout the years. In spite of this feasibility, not all procedures have brought evident benefits and, therefore, had its use resumed to isolated cases performed by extremely dedicated surgeons.
In this study, the vertical banded gastroplasty with Roux-en-Y gastric bypass proved to be technically feasible and performed in an identical way as the open surgery [12,13]. Superobese patients represented an important limitation to the laparoscopic approach, which was overcome through the use of adequate long instruments. The incidence of conversions to open surgery, as well as intra and postoperative complications was low. Hospital stay was similar to open surgery, even though it can still be reduced. Resumption to normal activities was short. Despite limited follow-up, remission or improvement of associated diseases and weight loss were adequate to and similar to open series [12,13]. When compared to the results of conventional surgery [15], a low incidence of early postoperative complications was observed. It was also demonstrated that there was an important decrease of complications specifically related to the approach in early as in late follow-up [12,13,15]. Operative time was longer after the laparoscopic approach.
The results of this study was similar to another published one [16], despite of a greater incidence of leaks even when compared to the data of open surgery. There was a straight relation between all the leaks and a specific type of stapler that was used. There were no more fistulas after discontinuing the use of this material.
In spite of the limitations imposed by the short follow-up and the reduced number of patients, it is possible that the laparoscopic vertical banded gastroplasty with Roux-en-Y gastric bypass offer significant advantages over the open approach in the treatment of morbid obesity.
1. Mason EE. Vertical Banded Gastroplasty for Obesity. Arch Surg 1982;117:701.
2. Sugerman HJ, Kellum JM, Engle KM, et al. Gastric bypass for treating severe obesity. Am J Clin Nutr 1992; 55:560S.
3. Kuzmak, LI. Stoma adjustable silicone gastric banding. Problems in General Surgery 1992;9:298.
4. Deitel M, Jones BA, Petrov I, et al. Vertical banded gastroplasty: results in 233 patients. Can J Surg 1986;29:322.
6. Lovig T, Haffner JF, Kaaresen R, et al. Gastric banding for morbid obesity. Int J Obes Rel metab Disord 1993;17:453.
7. MacLean LD, Rhode BM and Forse RA. Late results of vertical banded gastroplasty for morbid and superobesity. Surgery
8. Kuzmak LI. A review of seven years experience with silicone gastric banding. Obesity Surgery 1991;1:403.
9. Flickinger EG, Pories WJ, Meelheim HD, et al. The Greenville gastric bypass. Progress report at 3 years. Ann Surg 1984;199:555.
10. Pories WJ, Swanson MS, MacDonald, KG, et al. Who would have thought it? An operation proves to be the most effective therapy
for adult-onset diabetes mellitus. Ann Surg 1995;222:339.
11. Halverson JD. Metabolic risk of obesity surgery and long-term follow-up. Am J Clin Nutr 1992;55:602S.
12. Sugerman HJ, Kellum Jr JM, Reines HD, et al. Greater risk of incisional hernia with morbidly obese than steroid-dependent patients
and low recurrence with prefascial polypropylene mesh. The Am J Surg 1996;171:80.
13. Fobi, MAL, Lee, H, Holness R, Cabinda DG. Gastric Bypass Operation for Obesity. World J Surg 1998;22:925-935
14. Capella JF, Capella RF. The Weight Reduction Operation of Choice: Vertical Banded Gastroplasty or Gastric Bypass? The Amer Jorn
15. Gastrointestinal surgery for severe obesity: National Institutes of Health Consensus Development Conference Statement. Am J Clin
16. Mason EE, Tang S, Renquist KE, et al. A decade of change in obesity surgery. Obesity Surgery 1997;7:189.
17. Wittgrove Ac, Clark GW, Schubert KR. Laparoscopic Roux-en-Y gastric bypass. Technique and results in 75 patients with 3-30
months follow-up. Obesity Surgery 1996;6:500
8. Laparoscopic Malabsorptive Procedures. Laparoscopic Biliopancreatic Diversion With Duodenal Switch. Technique And Preliminary Results.
Michel Gagner, MD, FRCSC, FACS, Franz W. Sichel Professor of Surgery
Division of Laparoscopic Surgery, Department of Surgery, Mount Sinai School of Medicine, New York, New York.
Intermediate results with laparoscopic adjustable gastric banding, the most popular laparoscopic operation for morbid obesity in several countries, has been deceiving for superobese patients. At the time this abstract was written, the Food and Drug Administration in the United States is evaluating the results of the procedure. For these two main reasons, the most commonly performed laparoscopic bariatric operation in the United States is the laparoscopic Roux-en-Y gastric bypass. The early results of this approach compare favorably with the open approach, with fewer wound and pulmonary complications, decreased abdominal wall hernia formation and faster recovery. However, the long-term results of open gastric bypass published recently by MacLean et al., reports a 43% failure for superobesity BMI >50, which corresponds to the average american patient. For this reason, I have looked for an alternative in these patients in order to achieve a higher success rate longterm. The biliopancreatic diversion with duodenal switch as modified by Marceau from Scopinaro's initial operation appears to combine a restriction with a sleeve gastrectomy and a malabsorption by the creation of a duodeno-ileal anastomosis. This operation is the most common malabsorptive operation for obesity in America and can be performed laparoscopically.
The first step involves the opening of the gastrocolic omentum superior to the gastroepiploic arcade. All the transverse small vessels and short gastric vessels are coagulated with the ultrasonic coagulating shears. The proximal gastric fundic area can be quite difficult to access from subcostal trocars and the medial border of the spleen can be prominent with large folds of fat from the gasrto-splenic ligament hiding the dissection plane. The dissection will stop when one has reached the lateral border of the left crus or identified the gastro-esophageal junction. Then, I focused my attention to the distal antrum, inferior pyloric and proximal duodenal areas. Adhesions between the anterior part of the pancreatic body are frequently encountered posteriorly and have to be divided in order to adequately perform later the sleeve gastrectomy, otherwise too much stomach superiorly will be left.
The second part consists of the division of the duodenum with a laparoscopic stapler endo-GIA-II from USSC (Tyco Healthcare) with a 45 mm cartridge in length and 3.5 mm in thickness. The duodenum has to be prepared by dissecting superiorly close to the serosa of the duodenum to avoid any vascular injuries superiorly. The transection is performed 2-2,5 cms distal to the pylorus, farther than when one perform a pylorus-preserving pancreatoduodenectomy.
The sleeve gastrectomy is achieved by dividing the greater curvature of the stomach from the lesser curve longitudinally. Approximately 10 cms from the pylorus, an endoGia 60 mm long and 4.8 mm thick is used because the proximal antrum is thicker. The firing is done aiming towards the left side of the gastroesophageal junction. The anesthesiologist will insert a 60Fr bougie and this will be guided along the lesser curvature of the stomach with a laparoscopic babcock forceps, therefore preventing the creation of a too narrow lumen. Another firing of the same cartridge is done, and then 3-5 more firing of a thinner cartridge (3.5), same length, to complete the sleeve gastrectomy. The specimen is extracted using a large plastic bag and remove through the 15 mm trocar on the right side. A semi-rigid nasogastric tube 18 Fr is then used to construct an anvil passing tube to position the anvil in the duodenum, ready for the end to side duodeno-ileal anastomosis. The flexible anvil of a circular stapler CEEA -25 is used (Tyco Healthcare, USSC, Norwalk, Connecticut). A small duodenotomy is made and the tube retrieved from the peritoneal cavity through a trocar.
A very crucial step involves the exact measurement of the different bowel limbs involved, as it can impair and create a more pronounced micronutrient deficiency or result in inadequate weight loss. A pre-measured 50cms long umbilical tape is run on the antimesenteric side of the bowel using Dorsey laparoscopic bowel forceps of 5 mm (Karl Storz, Tutlingen, Germany) starting from the ileocecal valve until we reach 100 cm (twice the length of the umbilical tape). A silk suture 2-0 is applied to mark the future site of the enteroenterostomy. Then the bowel is run an additional 150 cms to make a total distal limb of ileum of 250 cms. At this point the bowel is transected with an endo-Gia 45 mm long and 2.5 thick. A small distance of mesentery is often taken with the ultracision (1-1.5 cm).
The duodenoileal antecolic anastomosis is performed using the CEEA-25 passed though the abdominal wall after the 15 mm trocar site has been. The end of the ileal limb is then closed with one or 2 firings of endo-GIA II 45 mm 2.5 mm thickness.
The last anastomosis, is performed usually by standing on the left side of the patient with the first assistant, and a side to side enteroenterostomy is achieved with the other segment of divided ileum and the 100 cm silk mark. A small enterotomy of 3-5 mm is on the antimesenteric side, and an Endo-GIA II 60-mm long 2.5 mm thick introduced, and fired once. The entorotomy is closed with a running suture of 2-0 silk with intracorporeal knot tying techniques.
Seventy two consecutive patients underwent laparoscopic BPD-DS as a primary procedure for morbid obesity in the first 15 months. Median patient body mass index (BMI) was 57.3 kg/ m2 (range 41-89 kg/ m2) with 75% of patients considered superobese (BMI >50). Mean age was 45 ± 1 years ( ± SEM) with 16 males and 56 females. All procedures were successfully performed laparoscopically except one. There were 2 intraoperative leaks. Median operative time was 200 minutes (range 110-360 minutes) with a significant correlation between BMI and operative time (p < 0.05). Mean blood loss was 150 ml. Median length of stay was 4 days (range 3- 210 days). There were 2 operative mortalities (30d). Major morbidities occurred in 12.5% patients including one anastomotic leak with a severe wound infection, one venous thrombosis, and four suture line hemorrhages. Follow up at 3, 6 and 12 months resulted in 32%± 3% , 46% and 60% excess body weight (EBW) loss. The post-operative quality of life appeared to be enhanced. All patients who were diabetic were off all treatment, 75% from anti-hypertensive by the third post-operative month, and 67% had a resolution from sleep apnea.
According to Marceau, the open duodenal switch results in a successful decrease of 78% of excess weight. When compared to a regular biliopancreatic diversion, the complications of anastomotic ulcerations, hypoproteinemia, diarrhea and dumping were less frequent and less pronounced. Recently, MacLean reported a subgroup of patients, with a BMI higher than 50, which was only successful in 40% of cases with an isolated gastric bypass. For this reason we have persisted in using a biliopancreatic diversion with duodenal switch for the superobese and beyond. Our relatively high operating time at this point may reflect a learning curve with the access method which correlated significantly with body mass index. A higher morbidity was encountered in patients with a BMI >65 (50% vs 8%). Our initial criteria for this operation has been patients with a BMI equal or above 60. We also have used it if patients need a gastric remnant in continuity with the GI tract for future follow-up, if there is inability to have a gastric bypass due to anti-arthritic medications, or if intelligent well informed compliant patients are asking for this specific modification.
I have found that the performance of an antecolic anastomosis is appropriate for most, because the anastomosis is lower in a duodenoileostomy that in an isolated gastric bypass, it seems better tolerated from the point of vue of tension. The duodenoileal anastomosis itself can be difficult to achieved if the ileum wall is thin and mesenteric fat pronounced. A hand-sewn technique with or without endo-GIA could also be used, with perhaps a longer operating time, and risk of leakage.
Reoperation for failed laparoscopic biliopancreatic diversion are anticipated, and maybe in the range of 5-10%. The inadequate weight loss may require a shortening of the common channel, or even the alimentary limb and those who will suffer from severe protein deficiency unresponsive to dietary modification, will need the reverse. This can be performed laparoscopically, as it has been performed in my own practice for Roux-en-Y gastric bypass failures.
In conclusion, this small experience and preliminary result shows that laparoscopic biliopancreatic diversion with duodenal switch is feasible. It may decrease the abdominal wall and pulmonary morbidity seen with the open approach. It will not decrease the gastrointestinal complications and nutritional problems seen with the open experience. A longer follow-up is needed to evaluate the weight loss and late complications. It may play a significant role in the management of superobese patients requiring surgical intervention.
1. Westling A, Bjurling K, Ohrvall M, Gustavsson S. Silicone-adjustable gastric banding: disappointing results. Obes Surg 1998; 8:467-474
2. Holeczy P, Novak P, Kralova A. Complications in the first year of laparoscopic gastric banding: is it acceptable? Obes Surg 1999; 9:453-455
3. Grandstrom L, Backman L: Technical complications and related reoperations after gastric banding. Acta Chir Scand 1987; 153:215-220Wittgrove AC, Clark CG, Schubert KR. Laparoscopic gastric bypass, Roux-en-Y: preliminary report of five cases. Obes Surg. 1995; 4:353-357
4. Scopinaro N, Gianetta E, Civalleri D, Bonalumi U, Bachi V. Bilio-pancreatic bypass for obesity: II.Initial experience in man. Br J Surg 1979; 66:618-620
5. Scopinaro N, Adami GF, Marinari GM, et al.: Biliopancreatic diversion. World J Surg 1998; 22:936-946
6. Hess DS, Hess DW. Biliopancreatic diversion with a duodenal switch. Obes Surg 1998; 8:267-282
7. Marceau P, Hould FS, Simard S, et al. Biliopancreatic diversion with duodenal switch. World J Surg 1998; 22:947-954
8. Gagner M, Garcia-Ruiz A, Arca MJ, Henniford B. Laparoscopic isolated gastric bypass for morbid obesity. Surgical Endoscopy 1999; 13:S6
9. Gagner M, Patterson E: Laparoscopic Biliopancreatic diversion with Duodenal switch. Digestive Surgery 2000
10. Ren C, Patterson E, Gagner M: Laparoscopic Biliopancreatic diversion with Duodenal Switch. Technique and preliminary results. Obesity Sugery 2000.
9. Hand-Assisted Laparoscopic Roux-en-y Gastric Bypass: Initial Experience
Associate Professor of Surgery, Director, Center for Minimally Invasive Surgery, Chief, Division of General Surgery, The Ohio State University
Surgery has become a well-accepted treatment for clinically severe obesity and its inherent comorbidities. A totally laparoscopic approach to bariatric surgery is associated with long operative times and a high rate of complications. We hypothesized that hand-assisted laparoscopic Roux-en-y gastric bypass is a good alternative to a pure laparoscopic approach and can be accomplished with significantly shorter operative times and acceptably low rates of complications.
Methods: The first thirty patients to undergo hand-assisted Roux-en-y gastric bypass at our institution were prospectively evaluated. All patients underwent operation with a relatively standardized technique performed by the same primary surgeon.
Results: Twenty-eight of 30 patients, with a mean BMI of 55.3 (range 41-84), successfully underwent hand-assisted gastric bypass surgery. The mean operative time was 279 minutes in the initial 10 patients, 243 minutes in the second 10 patients, and 162 minutes for the final 8 patients which was significantly less when compared with the first 2 groups (p<0.0001). Hospital length of stay ranged from 3 to 8 days with a mean stay of 4.75 days. Complications in the perioperative period were related to the wound, most notably 2 superficial wound infections (10.7%) and one hernia (3.5%). No anastomotic leaks were identified. Patient follow-up ranged from 1 to 14 months, with a mean of 5.7 months. One patient (3.5%) needed to return to the operating room 4 months after the original operation for revision of an anastamotic stricture and dilated proximal gastric pouch. Weight loss in the early post-operative period appears to be excellent and almost all patients report being very satisfied with the outcome of their operation.
Conclusion: Hand-assisted Roux-en-y gastric bypass can be successfully performed for clinically severe obesity with acceptably low perioperative morbidity. The hand-assisted approach is associated with shorter operative times when compared with a laparoscopic approach and is felt to improve tactile sensation, and facilitate retraction and exposure.
Key words: obesity, bariatric surgery, roux-en-y gastric bypass, hand-assisted laparoscopy
Surgery has become the treatment of choice to address the complications arising from clinically severe obesity [1,2,7,8]. Roux-en-y gastric bypass and vertical-banded gastroplasty are the most commonly performed of these procedures. Currently, gastric bypass is favored over vertical-banding and these patients can be expected to lose over 70% of their excess body weight. Indications for bariatric surgery include a body mass index (BMI) of 40 or a BMI of 35 or greater coupled with the comorbidities of obesity. Despite excellent results regarding weight loss, bariatric surgery is associated with complications such as, incisional hernias and wound infections, as well as cardiopulmonary complications[2].
Advances in surgical technology now offer patients the option of a minimally invasive approach to bariatric surgery. Laparoscopy offers the advantages of smaller incisions with less pain and therefore, shorter recovery and return to function. Both laparoscopic and hand-assisted roux-en-y gastric bypasses have been successfully performed; however, the laparoscopic approach is associated with long operative times and the lack of tactile sensation, making abdominal exploration and exposure difficult [5,6].
The hand-assisted approach allows the surgeon's hand to enter the abdomen through a relatively small incision and assist with the operation while maintaining pneumoperitoneum [3,4]. This report presents the experience of the authors with the 30 hand-assisted laparoscopic Roux-en-y gastric bypasses performed at our institution.
Patients (n=30) in this study were referred for surgery after evaluation by The Ohio State University Comprehensive Weight Management Center. Indications for surgery include a BMI of at least 40 or a BMI of 35 or greater with comorbidities attributable to their excess body weight. In addition, all patients must be evaluated and individually approved by the surgical team, clinical dietician, and behavioral science team. We document all failed attempts at intensive medical therapies for weight reduction and all patients must undergo nutritional counseling for at least one month prior to operation. After approval, informed consent is obtained for the procedure and the need for long-term follow-up. The same primary surgeon, using similar technique, performed the 30 procedures. Patients with prior upper midline incisions and those of extremely poor medical risk were excluded from the study.
Surgical procedure: Patients are admitted the day of surgery. They all receive pre-operative antibiotics and subcutaneous heparin and compression devices placed on both lower extremities or venous thrombosis prophylaxis. They are positioned supine on an operating table appropriate for their size and weight. A foley catheter was inserted and the abdomen prepped and draped in a wide sterile fashion. The right-handed, operating surgeon stands on the patient's left with an assistant on each side.
Initial incision is made in the supraumbilical midline approximately 10 cm below the xiphoid process. A Verres needle technique is used and the abdomen is insufflated to a pressure of 15 mmHg (this may be increased to 20 mmHg as needed). A 30 degree laparoscope is inserted and the abdomen explored. Four additional ports are placed under direct vision using standard technique. One 5 mm port in the subxiphoid region, 15-mm trocar placed subcostal in the right upper quadrant and two subcostal left upper quadrant 5/11 versa ports were placed. The original supraumbilical port is removed for placement of the Dexterity Pneumo Sleeve Set (Dexterity, Inc., Blue Bell, PA). The skin is marked and incision is made in the midline of the upper abdomen just large enough to allow the non-dominant hand of the surgeon (usually 6-8 cm).
The subxiphoid port is used for retraction of the left lobe of the liver. The gastroesophageal junction is dissected under direct vision using a combination of sharp and blunt dissection. Three centimeters distal to the gastroesophageal junction, the lesser omentum is divided from the stomach using the ultrasonic scalpel (Endosonics, USSC, Norwalk, CT). A window is developed along the lesser curve and the index finger of the surgeon's left hand is inserted behind the stomach. This allows clearance of the posterior wall of the stomach. The Endo GIA (USSC, Norwalk, CT) stapler is then used to staple divide the stomach in step-wise fashion, leaving a proximal 30 to 50 cc gastric pouch. This curvilinear transection should be carried out all the way to the fundus of the stomach, ending just lateral to the G-E junction.
Next, the Ligament of Treitz is identified. The small bowel is measured out approximately 20 cm to identify a redundant loop of jejunum for division and later anastamosis. The small bowel and mesentery are transected using the GIA stapling device (USSC, Norwalk, CT) and the distal limb is marked for later identification. If necessary, the mesentery can be further divided with the ultrasonic dissector for more mobility.
A retrocolic passage for the jejunal limb is preferred as many obese patients have redundant omentum that places the mesentery on unwanted tension. The transverse colon is elevated with the surgeon's hand and a rent is developed in the mesocolon using blunt dissection in an avascular area. The ultrasonic scalpel can be useful in enlarging this opening as needed. The appropriate limb of small bowel is then delivered through this opening and placed in apposition to the gastric pouch without tension. The anvil of a 25-mm EEA device is placed completely into the pouch of the stomach through a gastrotomy created with the ultrasonic scalpel, and the gastrotomy is restapled shut using an endo-GIA II (USSC, Norwalk, CT). The stem of the anvil is then brought out through the staple line. The right subcostal port is removed and an EEA is placed worked through the site into the abdomen and inserted within the lumen of the jejunum through an excised staple line of the roux limb. The gastroenterostomy is then created with the 25-mm. EEA stapler. The EEA stapler is removed and the end of the jejunum stapled closed using the endo-GIA II (USSC, Norwalk, CT).
Under direct palpation by the surgeon, the nasogastric tube can be positioned through the anastamosis and into the efferent limb. The anastamosis is tested for leaks with air insufflation through the nasogastric tube. Optional intracorporeal reinforcing sutures can then be placed using 3-0 silk sutures. At a point distal to the pouch, determined by the patient's BMI, 75 or 150-cm., a stapled jejunojejunal anastamosis is performed under direct vision by delivering the limbs though the pneumo sleeve port incision.
The abdomen is explored once again to identify bleeding and examine the anastamoses. When the surgeon is satisfied, fascial closure of the midline incision is performed using standard techniques. The fascia of the larger port sites were closed using laparoscopic techniques.
In the postoperative period, a nasogastric tube is left in place for at least 48 hours. Our patients are not routinely subjected to radiological evaluation and clear liquid diets are started on postoperative day #3 and advanced on liquids as tolerated. Prophylaxis for venous thrombosis is continued throughout the patient's hospital stay.
Data collection: Patients were entered in the study prospectively and information gathered from their medical records during hospital admission. Follow-up data was recorded by interview with the patients during routine follow-up visits in the surgeon's office, in the comprehensive weight management center, or by telephone interview.
Information obtained from interview included the patient's current weight, number of days to return to normal activity, information related to the incision, including any documented hernias or infections, and the presence of GI symptoms, including those specifically related to nausea, reflux, or abdominal pain.
Thirty consecutive patients were referred for a laparoscopic, hand-assisted Roux-en-Y gastric bypass at The Ohio State University Medical Center between June 1998 and August 1999. The mean BMI of these patients were 55.3 (range 41-84), 83% were female and there ages ranged from 19 to 52 years old with a mean age of 42.3 years. Twenty-eight patients (93.4%) successfully underwent the procedure. Two patients (6.6%) were converted to an open operation secondary to the surgeon's dissatisfaction with the anastomosis in one patient and the presence of an ovarian tumor in the second.
The mean operative time for the 28 patients was 279 minutes in the initial 10 operations, 243 minutes in the second 10 operations, and 162 minutes in the final eight patients which was significantly less when compared with the first 2 groups (p<0.0001).
In addition to gastric bypass, three patients underwent laparoscopic cholecystectomy (10.7%) and 1 patient underwent umbilical hernia repair (3.5%).
Hospital length of stay ranged from 3 to 8 days with a mean of 4.75 days. No postoperative leaks were identified in the early postoperative period. Eleven of 28 patients (39.3%) had early post-operative complications which included hernia (10.7%), wound infection (17.9%), skin breakdown (7.2%), and temporary ATN (3.6%). None of these complications required a second operation. However, one patient that was converted to an open operation required readmission and operation for a gastric bezoar.
Patient follow-up in this group ranged from 1 to 14 months. One patient required reoperation at 4 months postoperatively secondary to a dilated proximal gastric pouch and anastomtic stricture. This second operation was performed through a standard midline celiotomy incision. During routine follow-up patients mostly complained of nausea (53%), persistant mild abdominal pain (28.6%), bloating (21.4%), and reflux (14.3%). Other complaints included alopecia (7.2%) and persistent diarrhea (3.6%).
All patients at least 3 months postoperatively (n=19) were asked about their satisfaction with the operation, 18 patients reported they were "very satisfied" (94.7%) and the remaining patient stated she was still undecided.
Clinically severe obesity continues to be significant public health concern. Currently, surgery remains the only long-term solution for meaningful weight loss and the treatment of comorbidities that can result from excess body weight. Both roux-en-y gastric bypass and vertical banded gastroplasty are accepted as the two most effective operations to reduce excess body weight, however, roux-en-y gastric bypass appears to be more advantageous with the expectations to lose 70% of excess body weight.
Roux-en-y gastric bypass, although successful in its reduction of weight, carries a relatively high incidence of complications. Much of the morbidity of the procedure is related to the large incision necessary for abdominal access, as well as cardiopulmonary complications. The length and depth of incision make this operation susceptible to incisional hernias and wound infections. The recent advent of minimally invasive technique in bariatric surgery has encouraged many to bring the advantages of smaller incisions and diminshed post-operative pain to these patients. The prospect of fewer wound complications and earlier ambulation would be advantageous for bariatric surgery.
Feasibilty studies and small series have demonstrated that laparoscopic roux-en-y gastric bypass can be performed; however, it is associated with long operating times and the disadvantage of the lack of tactile sensation. In addition, retraction and exposure of the upper abdominal structures can be difficult and frustrating. Hand-assisted laparoscopy has been developed to overcome these shortcomings. Inserting the non-dominant hand into the abdomen through a relatively small incision, while maintaining pneumoperitoneum, adds the benefits of tactile sensation and facilitates retraction.
In our initial experience, the Dexterity (Pneumo Sleeve) greatly facilitated the operation with the benefits stated above. The roux-en-y gastric bypass was successfully performed with no post-operative leaks to date. Surgeons experienced with advanced laparoscopic procedures can expect a small learning curve using the hand-assisted approach. In fact, after the first 10 operations were performed the operative time was reduced by a mean time of 46 minutes. In addition, the 7 cm incision allows the surgeon to perform a jejunojejunostomy with staplers or hand sew under direct vision, without altering the incisions. In our series only one patient required conversion to an open operation secondary to dense adhesions from previous upper abdominal surgery.
Concerns in bariatric surgery and laparoscopy involve the use of standard laparoscopic instrumentation and its limitations in the morbidly obese. In our series, patients ranged from a BMI of 41 to as high as 84 (221.1kg.). Although these cases were more challenging, we do not feel that the size of the patient should contradict the hand-assisted technique.
Early complications from this operation are similar to that of the open operation in relation to the incisions. In fact, wound infections and hernias were most prevalent. Most of these infections and hernias involved the incision required for the pneumo sleeve. The early post-operative hernia was felt to be secondary to poor technique. Two hernias diagnosed in the post-operative period are being treated expectantly. None of the patients with infections required second operations and they were able to be treated locally. Fortunately, in this series, none of the patients experienced any cardiopulmonary complications or anastomotic leaks.
Two patients were noted to have skin breakdown after the operation, presumably from the operating room table. Neither of these patient's operative times were significantly different from the mean times. Care is always taken to ensure pressure areas are well padded.
Ninety-five percent of patients are "very satisfied" with the results of their operation, with one patient "undecided," secondary to persistent nausea and abdominal pain.
In the follow-up period many patients have had gastrointestinal complaints. These most commonly include nausea and bloating. In addition, persistent mild abdominal pain was reported for approximately two weeks after surgery with two patients complaining of moderate to severe pain for one year. Work-up has not revealed etiology for their pain and both have returned to work. Less frequently, symptoms of dumping, diarrhea and reflux have been reported but these symptoms were usually characterized as mild and few patients required medical therapy. Interestingly, none of these complaints affected the patient's satisfaction with their operations.
At The Ohio State University, hand-assisted laparoscopy has been utilized for complex, advanced laparoscopic procedures with modest success. We are encouraged by the results achieved in the first 21 patients and will continue to perform this operation. We are currently prospectively comparing hand-assisted laparoscopic roux-en-y bypasses to the same open operation perfomed by other surgeons at the same institution. In addition, we realize the need for long-term follow-up studies and will continue to follow these patients closely.
Currently, hand-assisted roux-en-y gastric bypass surgery is a viable alternative in bariatric surgery when coupled with thorough pre-operative evaluation and preparation for surgery. It is considered an advanced laparoscopic procedure and should be performed by surgeons who are comfortable and experienced with these techniques and are familiar with the complexities associated with the perioperative care of the morbidly obese patient.
The Center for Minimally Invasive Surgery at the Ohio State University is
funded in part by the United States Surgical Corporation, a division of Tyco Healthcare.
1. NIH (1992) Consensus Development Conference. Gastrointestinal surgery for severe obesity. Am J Clin Nutr 55: 615S-9S
2. MacLean LD, Rhode BM, Sampalis J, Forse RA (1993) Results of the surgical treatment of obesity. Am J Surg 165: 155-62
3. O'Reily MJ, Saye WB, Mullins SG, et al (1996) Technique of hand-assisted laparoscopic surgery. J Laparoendosc Surg 6(4): 239-244
4. Benelman WA, Ringers J, Meijer DW, de Wit CWM, Bannenberg JJG (1996) Laparoscopic-assisted colectomy with the DexterityTM PneumoSleeve. Dis Colon Rectum 39: S59-S61
5. Schauer PR, Ikramuddin S, Gourash W (1998) Laparoscopic roux-en-y gastric bypass: Initial results. (Abstract) Dig Disease Wk
6. Schauer PR, Ikramuddin S, Gourash W, Panzak G (1999) Laparoscopic roux-en-y gastric bypass for super-morbid obesity. (Abstract) Dig Disease Wk
7. NIH (1991) National Institutes of Health Consensus Development Conference Draft Statement on Gastrointestinal Surgery for Severe Obesity. Obesity Surg 1: 257-265
8. Sugerman HJ, Kellum JM, Engle KM, Wolfe L, Starkey T, Birkenhauer R, Fletcher P, Sawyer MT (1992) Gastric by-pass for treating severe obesity. Am J Clin Nutr 55: 5605-5665
9. Naitoh T, Gagner M, Garcia-Ruiz A, Heniford BT, Ise H, Matsuno S (1999) Hand-assisted laparoscopic digestive surgery provides safety and tactile sensation for malignancy or obesity. Surg Endosc 13: 157-160
10. Laparoscopic Weight Loss Surgery - Postoperative Care and Long-term Followup
Associate Professor of Surgery
Chief General and Gastrointestinal Surgery
Emory Clinic and Emory University School of Medicine
Surgical alteration of the gastrointestinal tract to alter nutrient intake and its absorption is an extremely effective way to induce weight loss of sufficient magnitude to ameliorate many of the medical consequences of severe obesity1. However, the operation and its associated anatomic alteration results in significant changes in dietary habits resulting food intolerances and nutritional deficiencies and metabolic problems. If not anticipated and managed early, serious permanent consequences may result. Programs offering operative approaches to weight control must have ongoing long-term follow-up and management strategies to educate patients and avoid these problems or diagnose and treat them early2, 3.
While patients undergoing laparoscopic weight loss surgery experience an enhanced postoperative recovery similar to that after other laparoscopic operations, due to the anatomic alteration of the gastrointestinal tract and its impact on postoperative diet, the postoperative recovery is most impacted by the diet progression prescribed postoperatively. The creation of a small gastric pouch (usually 15-30 cc) with either a restricted outlet or a gastrojejunostomy requires a very careful diet progression postoperatively. Typically, patients undergo a contrast swallow on the first postoperative day to rule out an anastomotic or staple line leak. After this study, patients are allowed clear liquids at 1 ounce each hour. Liquids with high sugar content are avoided since these may induce dumping. On the second postoperative day, if the limited clear liquids have been tolerated, patients are advanced to unlimited full liquid diet and are again seen by a dietician (all patients should see a dietician preoperatively to begin their postoperative diet teaching) for a review of the at home diet progression. Patients should remain on liquids for the first week postoperatively and over the subsequent 1-2 weeks advance to a pureed diet. Soft foods are not started until 3-4 weeks after surgery. This time allows healing, prevents premature pouch dilation, and slowly allows patients to adapt to their new diet and its volume and content restrictions. Patients are usually dismissed on postoperative day 2.
Other than diet progression, the most important part of in-hospital postoperative care is identifying complications. The most feared complication after weight loss surgery is leak from an anastomosis or staple line. The single most reliable indicator of a postoperative leak is persistent tachycardia after adequate fluid resuscitation. This finding should prompt a thorough investigation for leak. If leak cannot be demonstrated and tachycardia persists, the patient should be explored. Numerous studies have demonstrated intraabdominal leak in the presence of a normal temperature, WBC and abdominal examination, but with a persistent tachycardia.
Weight loss surgery requires a program for lifetime followup. This followup should be managed by the surgeon and not left to primary care physicians who are not familiar with the nutritional and metabolic consequences of these anatomic alterations. Also, problems with wounds, anastomotic stricture or bleeding, bowel obstruction and the development of other GI problems can occur after hospital discharge and are best identified and managed by surgeons. In the first year postoperatively, patients should be seen on a frequent basis to monitor weight loss, nutritional status and complications. An example schedule for followup is given in Table I.
NUTRIONAL AND METABOLIC ISSUES
Those bariatric procedures that do not bypass any portion of the gastrointestinal tract - restrictive operations - (e.g., vertical banded gastroplasty, gastric banding, etc.) have the lowest potential of resulting in significant nutritional deficiencies or metabolic problems. In the absence of early postoperative complications, the likelihood of nutritional or metabolic problems is extremely low4. However, there have been cases of irreversible Wernicke-Korsakoff encephalopathy (WE) and polyneuropathy reported after gastric partitioning for obesity5. The mechanism of this phenomenon has been felt to be related to acute thiamine deficiency secondary to excessive postoperative vomiting. In all cases reported in the literature WE or polyneuropathy occurred 2-3 months after surgery (20-365 days; mean 92 days) and all patients had persistent postoperative vomiting. Persistent vomiting in the postoperative period following purely restrictive procedures should prompt immediate evaluation and treatment, especially with thiamine replacement therapy.
Those procedures which bypass a portion of the gastrointestinal tract - malabsorptive procedures or combination malabsorptive/restrictive procedures - (e.g., gastric bypass, duodenal switch, pancreatobiliary bypass, etc.) may result in significant vitamin and nutrient malabsorption requiring routine replacement to avoid related long-term complications6.
For normal vitamin B12 absorption, dietary B12 must be released from its protein-bound source through the action of acid/peptic digestion. Operations which create a small proximal gastric pouch known to produce essentially no gastric acid or pepsin lead to inadequate release of dietary B12 and subsequent vitamin B12 deficiency7. Once thought to be the result of bypassing the gastric antrum, the source of intrinsic factor, and thereby short-circuiting the formation of the B12-intrinsic factor complex necessary for B12 absorption in the terminal ileum, it has now been determined that patients after gastric bypass have a normal schilling test when administered crystalline B12 orally. It is the nondigestion of protein-bound B12 which results in deficiencies8. The clinical consequences of vitamin B12 deficiency may not manifest for years after deficient B12 intake, and when clinically apparent some of the sequella are devastating and permanent (Wernicke-Korsakoff encephalopathy). For this reason, a program of routine vitamin B12 supplementation should be adhered to9. Due to poor release of B12 from typical capsules for vitamin B12 supplementation, options for B12 replacement after bariatric procedures include: 1) intramuscular injections of 1000mcg of cyanocobalamine on a monthly basis, either by patient self injection or through monthly office visits, 2) use of Nasocobal, a gel administered weekly intranasally and as effective as intramuscular injections. While crystalline B12 is absorbed in adequate amounts when administered orally, there is not yet any widely available oral formulation for crystalline vitamin B12.
The chief site of iron absorption is the duodenum. Since the duodenum is commonly bypassed in malabsorptive bariatric procedures, iron deficiency is a potential problem. This being said, clinically significant iron deficiency anemia is unusual following bariatric procedures. This is likely due to the tremendous ability of the intestinal epithelium to adapt its rate of iron absorption to the body's needs. Significant iron deficiency following bariatric procedures has been most commonly encountered in menstruating woman, and in this setting may even require intravenously administered iron dextran. The presence of some level of iron deficiency anemia in this group has been clearly demonstrated and we recommend routine iron supplementation in menstruating women with 320mg of iron twice daily10. Otherwise, oral supplementation through the administration of a daily multivitamin with iron is sufficient to avoid significant iron deficiency in non-menstruating patients.
It has been felt that gastric acid plays an important role in calcium absorption through its role in facilitating dissociation of food-calcium complexes and the solution of relatively insoluble calcium salts. Clearly, procedures which bypass the acid producing portion of the stomach will predispose to calcium malabsorption and deficiency. Additionally, much of the oral calcium is absorbed in the duodenum. For this reason we recommend the use of daily calcium supplements, either in the form of chewable tablets (Tums) or calcium slurries. While calcium replacement is easily administered and especially beneficial in woman who are always at higher risk for osteoporosis, there is very little evidence that the gastric bypass predisposes to calcium deficiency or metabolic bone disease10.
During the postoperative period caloric and nutrient intake will be significantly altered. A well designed diet progression under the supervision of a registered dietician or nutritionist is critical to ensuring safe weight loss. Many deficiencies can be avoid through a well balanced diet emphasizing the importance of protein intake, adequate hydration between meals, and incorporating the above listed supplements along with a daily multivitamin into one's dietary regimen. Specific supplements may be indicated on an individual basis. Hair loss is a common problem during weight loss and encouraging foods high in zinc (shellfish, eggs, lean meats) or a zinc supplement may minimize this hair loss.
Common to all procedures which induce weight loss are metabolic changes leading to gallstone formation11. Approximately 25% of patients after the rapid weight loss induced through surgery develop gallstones. Of these, half may develop symptomatic cholelithiasis or acute cholecystitis requiring cholecystectomy12. In series where every patient undergoing a bariatric operation had their gallbladder removed, a significant number had unsuspected stones or changes of chronic cholelithiasis on histologic examination13. This has prompted many surgeons to apply some method of prophylaxis against gallstone formation or to use routine cholecystectomy at the time of bariatric surgery14. What is the best way to handle the gallbladder at the time of surgery, or how to deal with the development of gallstones as a result of the metabolic changes induced by rapid weight loss remains unclear. Routine cholecystectomy exposes a significant number of patients to the morbidity of cholecystectomy unnecessarily. On the other hand, an expectant approach again exposes patients to the potential consequences of acute cholelithiasis or another operation. More recently the use of gallstone dissolution therapy during the period of weight loss has been shown to effectively decrease the risk of stone formation15, 16, however, the expense of this approach has been called into question. It is important for those surgeons running a bariatric program to have a strategy for managing the gallbladder both during and after bariatric procedures, and to inform the patient that one of the consequences of their weight loss may be the formation of and further surgery.
Finally, no approach to the prevention and management of nutritional and metabolic disorders will be successful with a strategy for long-term patient follow-up. While the areas of concern already discussed can be approached with proactive strategies for replacement and early recognition of problems, ongoing physician care of these patients is critical to the overall success of bariatric procedures. This care is best provided within a program in bariatrics, or by surgeons who are performing these procedures and are familiar with the common conditions that may develop postoperatively. Below is a proposed strategy for follow-up. To operate and relegate these patient's care to physicians who are not familiar with the sequella of these anatomic alterations will result in complications that will continue to allow the existing biases against bariatric surgery to persist thereby continuing to compromise our ability to offer proven treatments to these desperate people.
EXAMPLE OF POSTOPERATIVE FOLLOW-UP STRATEGY
1. Mun EC, Blackburn GL, Matthews JB. Current status of medical and surgical therapy for obesity. Gastroenterology 2001(120):669-681.
2. Higa KD, Boone KB, Tienchin H. Complications of the laparoscopic Roux-e-Y gastric bypass: 1,040 patients - what have we learned? Obesity Surg 2000(10):509-513.
3. Schauer PR, Ikramuddin S, Gourash W, et al. Outcomes after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Ann Surg 2000; 4(232):515-529.
4. Balsiger BM, Kennedy FP, Abu-Lebdeh HS, et al. Prospective evaluation of Roux-en-Y gastric bypass as primary operation for medically complicated obesity. Mayo Clinic Proceedings 2000; 75(7):673-80.
5. Cirignotta F, Manconi M, Mondini S, et al. Wernicke-korsakoff encephalopathy and polyneuropathy after gastroplasty for morbid obesity: report of a case. Archives of Neurology 2000; 57(9):1356-9.
6. Brolin RE, Gorman RC, Milgrim LM, Kenler HA. Multivitamin prophylaxis in prevention of post-gastric bypass vitamin and mineral deficiencies. International Journal of Obesity 1991; 15(10):661-7.
7. Smith CD, Herkes SB, Behrns KE, et al. Gastric acid secretion and vitamin B12 absorption after vertical Roux-en-Y gastric bypass for morbid obesity. Annals of Surgery 1993; 218(1):91-6.
8. Behrns KE, Smith CD, Sarr MG. Prospective evaluation of gastric acid secretion and cobalamin absorption following gastric bypass for clinically severe obesity. Digestive Diseases & Sciences 1994; 39(2):315-20.
9. Brolin RE, Gorman JH, Gorman RC, et al. Are vitamin B12 and folate deficiency clinically important after roux-en-Y gastric bypass? Journal of Gastrointestinal Surgery 1998; 2(5):436-42.
10. Brolin RE, Gorman JH, Gorman RC, et al. Prophylactic iron supplementation after Roux-en-Y gastric bypass: a prospective, double-blind, randomized study. Archives of Surgery 1998; 133(7):740-4.
11. Faloon WW. Hepatobiliary effects of obesity and weight-reducing surgery. Seminars in Liver Disease 1988; 8(3):229-36.
12. Shiffman ML, Sugerman HJ, Kellum JM, et al. Gallstone formation after rapid weight loss: a prospective study in patients undergoing gastric bypass surgery for treatment of morbid obesity. American Journal of Gastroenterology 1991; 86(8):1000-5.
13. Schmidt JH, Hocking MP, Rout WR, Woodward ER. The case for prophylactic cholecystectomy concomitant with gastric restriction for morbid obesity. American Surgeon 1988; 54(5):269-72.
14. Mooney MJ, Carter PL. Routine cholecystectomy in the morbidly obese. Military Medicine 1989; 154(8):409-11.
15. Sugerman HJ, Brewer WH, Shiffman ML, et al. A multicenter, placebo-controlled, randomized, double-blind, prospective trial of prophylactic ursodiol for the prevention of gallstone formation following gastric-bypass-induced rapid weight loss. American Journal of Surgery 1995; 169(1):91-6; discussion 96-7.
16. Worobetz LJ, Inglis FG, Shaffer EA. The effect of ursodeoxycholic acid therapy on gallstone formation in the morbidly obese during rapid weight loss. American Journal of Gastroenterology 1993; 88(10):1705-10.
11. Proximal Gastric Bypass Long Term Outcomes
Alan Wittgrove, MD, FACS; G. Wesley Clark, MD
12. CODIFICATION OF THE LAP-BAND AFTER 1000 PROCEDURES
CADIERE G.B., FAVRETTI F., SEGATO G., HIMPENS J.
The patient lies supine, thighs fully abducted and slightly bent. The operating table has a 30° reversed Trendelenburg tilt. The surgeon stands between the patient's legs, the first assistant to the patient's left and the second assistant to the right.
A long Verres needle is introduced above the umbilicus so as to avoid the fatty hepatic ligament. Intra-abdominal pressure is maintained at 15 mm Hg.
3. Placement of trocars and instrumentation
Five trocars are placed in the following sequence : a 10 mm trocar for a 30° optical system 6 fingerbreadths below the xiphoid; a 10 mm trocar for the liver retractor (subxiphoid); a 10 mm trocar for a grasping forceps and the Lap-Band Closure Tool (in right upper quadrant); a 5 mm trocar for the cautery hook, needle holder and grasping forceps (in left upper quadrant); and a 10 mm trocar for an atraumatic grasping forceps replaced later on by a 18 mm trocar for band introduction and reservoir placement (on the left anterior axillary line below the costal margin).
4. Dissection of the phrenogastric ligament
The gastric fundus is pulled distally by the grasper in the most lateral left trocar, hereby putting the phrenogastric ligament under tension. A small window is now created in this ligament by using the coagulation hook. Location of this second window is usually half way between the upper pole of the spleen and the esophagus or the left side of the left crus.
The anaesthetist introduces a balloon tipped naso gastric tube inside the stomach.
25 cc of fluid are injected in the intragastric balloon after which the balloon is pulled back until it is blocked at the G.E. junction. The bulge seen on the stomach allows the surgeon to decide on the level of initial dissection. The correct level is the equator of the bulge. This level is then marked by scoring the peritoneum on the lesser curvature with the coagulating hook.
The lesser curvature is dissected with the coagulating hook about 2 cm distal to the GE junction. The grasping forceps coming from the right upper quadrant grasps the gastrohepatic ligament while another grasping forceps coming from the most lateral trocar grasps the gastric wall. This puts the peritoneum on the lesser curvature under tension. Dissection should be undertaken as close as possible to the gastric wall, with care being taken not to damage it, and should preserve the nerve of Latarjet. Under direct vision the full thickness of the hepatogastric ligament is dissected from the gastric wall so as to make a narrow and limited opening. The way of dissection is above the reflexion of the peritoneal sheet covering the lesser sac.
An gastric forcep is introduced in the right upper quadrant trocar and is advanced in the retrogastric tunnel under direct vision. The instrument is then curved and its tip becomes visible in the dissection area of the phrenogastric ligament. The coagulating hook can deal with the remaining fibrous strings, and the endograsp is advanced until it emerges above the spleen where the diaphragm is grasped.
8. Introduction and placement of the LASGB
The most lateral 10 mm trocar is replaced by an 18 mm cannula. A silicone band (BioEnterics, Carpinteria, California) with its tubing is introduced intraperitoneally, grasped by the grasping forceps and looped around the stomach at the level of dissection. The tip of the tubing is introduced in the locking area of the band. The silicone band is tightened around the stomach.
The anaesthetist reinsufflates 15 mL in the balloon tipped nasogastric tube and again pulls it back until it hits the GE junction. The surgeon can now be certain of the correct positioning of the band. The band is tightened and locked.
10. Suture stabilisation of the LASGB
Four to five stitches are placed between the serosa of the stomach just proximal and distal to the band to avoid slipping.
11. Placement of the injection reservoir
The 18 mm port is removed, and the nonkinking tube is cut to an appropriate length and connected to the injection reservoir. The reservoir, is burried, convex side up, and stitched to the anterior thoracic fascia overlying the costal margin to the left.
The reservoir enables adjustments of the fascia stoma by inflating the gastric band.
This adjustment is performed by a radiologist one month after surgery. Stoma size will be established depending on complications (reflux, food intolerance), on the weight loss curve and on the radiograph.
13. Laparoscopic Adjustable Gastric Banding: Current Status of the FDA Trial
i. BioEnterics Laparoscopic Adjustable Gastric Banding System ®
A. Self-locking band with an inner inflatable balloon
B. Access port similar to a Mediport ®
B. Minimal dissection to create a retro gastric/esophageal tunnel
D. Imbrications of stomach over band
E. Attachment and imbedding of access port into rectus muscle facia
III. Peri-Operative Management
A. Must select the right patients, nonsweet eaters
B. Patients need more peri-operative behavior modification counseling than gastric bypass patients
C. The band usually needs to be adjusted several times the first year. Patients who asked for frequent adjustments are asking the band to do too much and need more counseling
D. Avoid vomiting or overrating
A. 300+ bands placed between June 1995 and present
B. Awaiting 3 year follow-up on the first 250 patients who had procedures between 1995-1998
C. Patients very satisfied with the trial, some surgeons are not
D. Unclear how many patients will request conversion to gastric bypass or other procedures
E. Revision rate between 10/20%. It improves with experience
A. Trial results have been submitted to the FDA
B. An expedited review has been requested
C. Training seminars are being organized
D. It is not clear whether insurance programs will support the band as an obesity treatment
14. Laparoscopic Gastric Banding for the Treatment of Severe Obesity/ Latin American Experience
Hospital Santa Engracia, Monterrey, NL, Mexico
15. Complications of Surgery for Severe Obesity
Robert E. Brolin, M.D., F.A.C.S.
UMDNJ-Robert Wood Johnson Medical School St. Peter's University Hospital
Gastrointestinal operations performed for treatment of morbid obesity are complex procedures incorporating measures to provide either restriction of oral intake, malabsorption of ingested nutrients or both, Consequently these operations are associated with a variety of complications including nutritional deficiencies. The incidence, nature and potential remedies for these complications are discussed.
Obesity is firmly established as a risk factor for cardiovascular disease and premature death (1, 2) . The mortality risk increases markedly above the 50% overweight level which is still below the lower weight limit required to qualify for surgical treatment. In addition to the negative health consequences of obesity, virtually every surgeon acknowledges obesity as a factor which increases the incidence of major postoperative complications. The high risk associated with operations in patients with severe obesity was evident in the early morbidity and mortality statistics associated with both gastric and intestinal bypass. However, in the past decade the morbidity and mortality rates reported in large series of bariatric operations are in the range of 10% and < 1% respectively (3, 4, 5).
In experienced hands intraoperative complications during bariatric operations are relatively rare. These can be divided into three categories: bleeding (including splenic injury), inadvertent injury to the GI tract and stapling misadventures. Table 1 shows the incidence of intraoperative complications in the author's series of 1125 consecutive operations over 18.5 years. All major bleeding was related to splenic injury. Splenectomy was not required in any case. However, two splenorrhapies were performed to control bleeding. No patient required reoperation for bleeding. Each of the visceral injuries was iatrogenic. There were 4 esophageal injuries incurred during blunt manual mobilization of the gastroesophageal junction and 2 lacerations of the jejunum created by intestinal staplers. All but one of the injuries was recognized and repaired intraoperatively. One of the esophageal injuries was not recognized until 24 hours later. This patient recovered after a stormy four month convalescence. The stapling misadventures included one misfiring of the old nondisposable TA 90 stapler very early in the author's experience and 3 inadvertent staplings of the NG tube. The TA 90 misfiring resulted in a laceration of the cardia which was repaired but subsequently leaked. Stapling the NG tube in each case occurred during a break in the routine progress of the operation. The stomach was repaired or restapled after the NG tube was extracted. These patients recovered uneventfully. In summary, although intraoperative complications can generally be avoided by unabated concentration and careful technique, the injuries described above can be successfully corrected or repaired if recognized intraoperatively.
EARLY POSTOPERATIVE COMPLICATIONS
Pulmonary embolism is the leading cause of perioperative death in bariatric surgical patients with a mortality rate in the range of 20-30%. Fortunately, the incidence of pulmonary embolism is reported in the range of 1-2% in most large series of bariatric operations (3, 4, 5). Although nearly all bariatric surgeons use some method of perioperative DVT prophylaxis, the incidence of pulmonary embolism does not seem to be altered by routine use of intermittent decompression stockings or subcutaneous heparin. Early postoperative ambulation is always emphasized and is surprisingly well tolerated by most patients. A recent study by Martin et al, reported that recommended doses of LovinoxR often do not attain acceptable levels of factor XA, an indicator of therapeutic efficacy (6). DVT in the absence of embolism is quite uncommon in bariatric patients with a reported incidence of less than 1.0%. Both peripheral DVT and pulmonary embolism are treated using conventional methods of anticoagulant therapy.
The incidence of gastrointestinal leaks after primary gastric bariatric operations is reported in the range of 1-2% (3, 4, 7). Gastrointestinal leaks may be difficult to recognize in bariatric surgical patients because fever and abdominal tenderness are frequently absent during the first 48 hours after a leak has occurred. The leukocyte count is often elevated but may be within normal limits. An isolated left-sided pleural effusion is a common finding on the plain chest radiograph. Persistent tachycardia and progressive tachypnea are the most common early signs. Hence, it is common to initially suspect pulmonary embolism in a patient with a gastric leak. In this setting it is reasonable to order a ventilation/perfusion scan as a first diagnostic test. Most surgeons attempt to identify leaks using radiographic gastrointestinal contrast studies. However, a normal contrast study by no means excludes a leak since extravasation from the gastric staple line is usually not identified by upper GI contrast studies. Because failure to recognize a leak can result in death, exploratory laparotomy should be empirically performed in patients with progressive tachypnea and tachycardia in whom pulmonary embolism has been ruled out. In patients who are rapidly deteriorating, exploratory surgery should be undertaken without gastrointestinal radiographs. The incidence of leaks following revision procedures is 5-10 times higher than after primary operations presumably due to problems with ischemic damage to the stomach. Although the published mortality rate of leaks is in the range of 10-20%, it is likely higher in the hands of less experienced surgeons.
The incidence of major wound infection after gastric restrictive operations is reported in the range of 1-3% (3, 4) . Conversely, seromas in the subcutaneous fatty layer are common with an incidence approaching 40% in the author's series. Both seromas and subcutaneous wound infections should be treated as conservatively as the condition allows. Although most seromas drain spontaneously, evacuation of additional fluid by the surgeon is usually required. This can be easily accomplished using a sterile cotton tip applicator. It is rarely necessary to open the wound more than 5-10mm to evacuate a seroma. However, additional drainage interventions are often necessary and can be accomplished by either the patient or visiting nurses.
In the author's experience most wound infections in bariatric patients evolve from inadequate treatment of seromas. Wound infection in the absence of a preexisting seroma is rare. Although subcutaneous wound infections rarely require opening the entire incision, the wound must be opened sufficiently to achieve adequate drainage. With vigilant outpatient wound care hospitalization and parenteral antibiotics are rarely necessary. Secondary, healing of open subcutaneous wounds in bariatric patients is a lengthy process.
The potential for wound dehiscence after bariatric operations is greatly increased due to the tension placed on the closure by massive overweight. The incidence of facial dehiscence is < 1.0% in large clinical series (3, 8) . Hence, the abdominal fascia should be closed with heavy absorbable or nonabsorbable suture. The author now routinely uses a continuous double-stranded suture of #1 PDS for fascial closure after having three cases of midline fascial dehiscence following closure with interrupted #1 EthibondR sutures (8). Healing of the skin incision after bariatric operations is also problematic. In the author's early experience two patients developed almost complete dehiscence of the skin incision within the first 10 days postoperatively. However, during the last 15 years we have routinely removed less than half of the skin staples prior to discharge. Steri strips are placed between the remaining staples which are removed 7-10 days later. There have been no problems with major skin wound discence since adopting this practice.
Table 2 and 3 show the early and late postoperative complications in the author's series of 669 consecutive primary gastric restrictive operations performed over a 15 year period. Although the incidence of complications was remarkably similar in gastroplasty and RYGB patients, there was a notable difference in the nature of the late complications between the two procedures. Two of the three cardiac arrests in Table 2 resulted from inability to intubate patients who developed acute respiratory distress. Intubation under these difficult circumstances should be deferred to experienced health professionals who have skills in awake intubation. In the author's experience major atelectasis and pneumonia are rare complications of gastric bariatric operations. The cases of GI bleeding within the 30 day perioperative interval included a variety of causes including two marginal ulcers, one gastric pouch ulcer, and one case of staple line bleeding. Although all but one of these four patients required blood transfusion, none required reoperation.
Incisional hernia is the most common late complication after gastric restrictive operations with an incidence ranging from to 10-20% in most large series (4, 8, 9). Repair of hernias involving more than 10-15% of the length of the incision is best performed using prosthetic mesh. Use of sutures alone for repair of large hernias is associated with a high rate of recurrence (9) . We have reduced the incidence of hernias by approximately one-half by using a double-stranded suture of #1 PDSR to
The incidence of symptomatic gallbladder disease after bariatric operations varies from 3% to greater than 30% (10, 11) . Hence, removing the gallbladder "prophylactically" at the time of surgery is a controversial issue aiuong bariatric surgeons. Several surgeons who have recommended prophylactic cholecystectomy report histologic evidence of gallbladder pathology in nearly 90% of cases. Other surgeons believe that the incidence of symptomatic cholecystitis after gastric restrictive operations is not high enough to justify routine removal of the gallbladder in patients who do not have gallstones. Most surgeons who perform malabsorptive operations such as biliopancreatic bypass or the duodenal switch advocate prophylactic cholecystectomy because of the high incidence of postoperative gallbladder disease (12). The risks of adding cholecystectomy to an elective bariatric procedure are negligible.
A multi-center, randomized, double-blind, prospective trial recently evaluated three oral doses of Ursodiol (Actigall R) versus placebo during the first 6 months after RYGB. Of the 233 patients who had postoperative ultrasonography gallstones formed in 32% of the placebo group vs. 4% of the higher dose treatment groups. The investigators concluded that Ursodiol at doses of 600 and 1200 mg per day was effective in preventing cholelithiasis during the rapid weight loss phase after gastric bypass (11). Because cholelithiasis is a known risk of rapid weight loss, the author routinely recommends a 6-12 month course of Ursodiol after RYGB.
Although vomiting is a common side effect of most gastric restrictive operations, severe, intractable vomiting is quite rare. Most cases of severe vomiting have followed banded gastric restrictive operations and are usually caused by stenosis of the outlet stoma. Patients with vomiting who cannot tolerate liquids should be hospitalized and placed on intravenous fluids. In many cases the edema of the outlet stoma that results from protracted vomiting will resolve without further intervention. Patients who cannot tolerate liquids after several days of nothing by mouth and intravenous fluids should undergo upper endoscopy and stomal dilatation using balloon tipped catheters. Stomal dilatation is frequently problematic in patients with prosthetic stomal reinforcement. Conversely, endoscopic dilatation is almost always successful after RYGB. Many patients with banded restrictive procedures require revision for intractable stomal stenosis.
Late disruption (breakdown) of the stapled gastric partition is responsible for patients regaining lost weight after gastric restrictive operations. The incidence of staple line breakdown varies widely in clinical reports. In an assiduous follow up study, MacLean, et al found a nearly 50% incidence of staple disruption during a 5 year period after vertical banded gastroplasty (5) . Conversely, Sugerman et al, report a less than 2% incidence of late breakdown after RYGB (13). Pories et al, reported a > 10% incidence of staple disruption over 10 years after RYGB (14) which lead to a prospective trial of stapling with transsection of the upper stomach. Pories group abandoned transsection after 100 cases when they observed that dividing the stomach neither eliminated subsequent gastro-gastric fistulization nor reduced the incidence of leaks (14). Despite conflicting data most surgeons are now routinely dividing the stomach during gastric bariatric operations. The incidence of staple line leaks and gastrogastric fistulae after transsection are in the range of1-2%.
The reported incidence of marginal ulcer after RYGB and BPB ranges from 3-10% (3, 12, 15, 16). These ulcers typically develop on the jejunal side of the gastroenterostomy (Figure 1) and are caused by excessive production of gastric acid. Serum gastrin levels are typically normal or subnormal. Patients typically present with burning epigastric pain or painless GI bleeding. Bleeding is usually manifested as melena rather than hematemesis. After RYGB this potentially serious complication is frequently associated with breakdown of the gastric staple-line. Marginal ulcers that are not associated with disruption of the stapled gastric partition almost always respond to H2 blockers or proton pump inhibitors. Conversely, ulcers that occur in patients with staple-line breakdown are often intractable to medications and require operative treatment. Operations for intractable ulcers should include resection of the ulcer, revision of the gstroenterostomy and restapling of the stomach with transsection for gastric staple-line breakdown.
Although intestinal obstruction is relatively uncommon after bariatric opeations, it is occasionally life-threatening. Bowel obstruction is rare after gastroplasty and gastric banding. The incidence of SBO after RYGB and other malabsorptive procedures is in the range of 2-3% (4). Although most cases of SBO develop months or years after the primary bariatric procedure, obstruction within the first few days also occurs. Because gastric capacity is greatly reduced after RYGB and BPB, vomiting is often not a prominent symptom. Most cases of early obstruction can be successfuly treated by tube decompression which is best accomplished using fluoroscopy. Although most cases of late SBO are caused by adhesions, volvulus related to internal hernia is a recognized, occasionally fatal type of obstruction. Because obstruction of the bypassed bowel may not be obvious on plain abdominal radiographs, CT scanning should be promptly performed when abdominal films are nondiagnostic. An aggressive attitude towards operative treatment is warranted in patients whose symptoms are not quickly improved with tube decompression.
Patients who have either RYGB or BPB are at risk for developing metabolic sequelae as a consequence of malabsorption. Table 4 shows the incidence of metabolic complications which are typically associated with gastric bypass. Since iron absorption occurs primarily in the duodentuu, malabsorption of ingested iron is the primary cause of of post gastric bypass iron deficiency. Vitamin B-12 deficiency after gastric bypass is the result of failure to cleave food bound B-l2 in the upper gastric pouch (17). Conversely, crystalline B-l2 is absorbed normally in the distal ileum. Although the cause of folate deficiency after gastric bypass is unknown, inadequate dietary intake is probably the most likely etiology. Deficiencies in each of these micronutrients can result in anemia.
Because these deficiencies are common, daily prophylactic multivitamin/mineral supplements are recommended for all patients who have RYGB or malabsorptive procedures. However, the efficacy of multivitamins alone in prevention of iron and vitamin B-l2 deficiency is not clearly established. Conversely, multiviamins have been shown to reliably prevent folate deficiency after RYGB (18, 19). In our experience menstruating women are particularly prone to iron deficiency and anemia after RYGB. In a recent prospective randomized study we reported that prophylactic oral iron supplements consistently prevented iron deficiency in menstruating women after RYGB (20) . However, we were surprised to find that the incidence of anemia was similar in women who received placebo rather than iron. Anemia in the absence of a measurable metabolic deficiency remains problematic in a small number of patients who have RYGB. Fortunately the majority of post gastric bypass vitamin and mineral deficiencies are mild and easily corrected with oral supplements of the deficient micronutritent. Injection therapy is rarely required in patients who willing to take oral supplements. Hospitalization for treatment of these deficiencies is extremely uncommon.
Because fat malabsorption is a primary component of both BPB and the duodenal-switch, patients who have these procedures are prone to develop deficiencies in fat soluble vitamins. Sugerman recently reported a high incidence of serious metabolic sequelae during the first year after BPB in a series of 25 superobese patients (21). More than half of Sugerman's BPB patients had deficiencies in fat soluble vitamins. Calcium deficiency and hypoproteninemia have been noted in 10-20% of BPB patients. Moreover, approximately 3% of the lighter patients ( <220% overweight) in Scopinaro's series became "underweight" with gross manefestations of protein/calorie malnutrition (12) . Marceau, et al, recently reported a comparative study of the duodenal switch vs. conventional BPB which disclosed significant reduction in the incidence of hypocalcemia, hypoalbu.minemia, anemia and malodorous flatus in patients who had the duodenal switch (22) . The duodenal switch has the additional theoretical advantage of preserving the parietal cell mass in the stomach which should virtually eliminate postoperative vitamin B-l2 deficiency. However, there are no published data on the incidence of B-l2 deficiency after either BPB or the duodenal switch.
In summary the incidence and severity of complications following bariatric operations must be balanced against the benefits of these procedures. In the author's experience it is unusual to find a bariatric surgical patient who would not "do it all over again" even after suffering a major complication. As we approach the millennium surgery remains the only effective treatment for patients with morbid obesity.
Table 2: *Two of the three patients who suffered cardiac arrest could not be successfully resuscitated for an overall mortality rate of 0.3% (2/669)
Table 4: Mean incidence and time of deficiency recognition are listed under each micronutrient with mean follow up shown in right column.
Figure 1: Large marginal ulcer (arrow) in jejunum just beyond gastrojejunostomy. The upper pouch is small; stapled gastric partition is intact.
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