James G Bittner IV, MD, Gretchen Aquilina, DO, Luke Wolfe, MS, Jill Meador, RN, James W Maher, MD, John M Kellum, MD. Virginia Commonwealth University School of Medicine.
INTRODUCTION: The purpose of this study was to ascertain the 30 and 90-day procedure-related morbidity and mortality of laparoscopic Roux-en-Y gastric bypass (LRYGB) at a single university hospital to facilitate consistent patient counseling and informed consent.
METHODS: Retrospective review of a prospectively maintained database was conducted on all patients who underwent primary LRYGB at an American College of Surgeons Bariatric Surgery Center of Excellence from 1998-2012. LRYGB technique and postoperative management algorithms were standardized and consistent throughout the study period. LRYGB was performed in a retrocolic, retrogastric fashion with linear stapled anastomoses. Data assessed were patient demographics and postoperative outcomes at 30 and 90 days including rates and severity of wound infection, leak, marginal ulcer, stomal stenosis, bowel obstruction, internal hernia, incisional hernia, venous thromboembolism, readmission, and overall morbidity and mortality. Additional outcomes included primary procedure-related reoperation rate and the type of intervention required.
RESULTS: In total, 1,597 patients underwent LRYGB. Most were available for follow-up at 30 (96.7%) and 90 days (98.7%). Mean patient age and body mass index (BMI) were 42.1 ± 11 years and 48.9 ± 7.8 kg/m2, respectively. Most patients were female (84.6%) and Caucasian (76.6%). Overall 30 and 90-day morbidity were low (10% and 15%). The higher 90-day morbidity was due, in large part, to the increased incidence of marginal ulcer and stomal stenosis diagnosed between 31 and 90 days (Table 1). In all, 70 patients (4.4%) required reoperation for gastrointestinal leak (n=48) and small bowel obstruction (n=22). The majority of reoperations were required within the first 30 days postoperatively. No invasive treatments were required for other assessed complications. Of 91 patients readmitted within 90 days, principal admission diagnoses were abdominal pain (38%), nausea/vomiting (35%), bowel obstruction (3%), infection (8%), venous thromboembolism (6%), gastrointestinal bleeding (4%), and other (4%). The 30-day mortality rate was low (0.6%) with no death occurring between 31 and 90 days.
Table 1. Short-term morbidity of 1,597 primary gastric bypasses | ||
Complication (%) | 30 days (n=1,545) | 90 days (n=1,576) |
Minor infection | 8 (0.5) | 9 (0.6) |
Major infection | 7 (0.5) | 7 (0.4) |
Gastrointestinal leak | 68 (4.4) | 68 (4.3) |
Marginal ulcer | 15 (1) | 53 (3.4) |
Stomal stenosis | 13 (0.8) | 42 (2.7) |
Bowel obstruction | 23 (1.5) | 30 (1.9) |
Internal hernia | 1 (0.1) | 4 (0.3) |
Incisional hernia | 11 (0.7) | 15 (1) |
Venous thromboembolism | 13 (0.8) | 14 (0.9) |
Readmission | 62 (4) | 91 (5.8) |
Reoperation | 62 (4) | 70 (4.4) |
Complication rates reported at 90 days are cumulative. | ||
CONCLUSIONS: In a large single-institution series of LRYGB, short-term outcomes demonstrated low rates of overall morbidity and mortality. The most common complication and indication for reoperation was gastrointestinal leak. The increased incidence of marginal ulcer and stomal stenosis from 30 to 90 days contributed to higher rates of readmission and overall morbidity. Patient counseling about the potential complications of LRYGB should include a risk frequency profile compiled from local outcomes data whenever possible.
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