Teaching and Good Results Can Go Hand in Hand in Bariatric Surgery: 1733 Consecutive Laparoscopic Gastric Bypass Cases at a Teaching Center Without Gastro-jejunostomy Leak

Ashutosh Kaul, MD FRCS FACS, Anthony Maffei, MD FACS, Thomas Sullivan, BS, Edward Yatco, MD FACS, Thomas Cerabona, MD FACS, Niu Zhang, MD. New York Medical College

Aim of this presentation is to communicate our series of 1733 consecutive laparoscopic gastric bypasses done at a teaching center without any leak from the gastro-jejunostomy and to highlight the fact that both teaching and good results in bariatric surgery can go hand in hand .

This is a retrospective analysis of prospectively maintained data from a tertiary care center. Data was analyzed from January 2001 till June 2011. Redo cases, sleeve gastrectomies, lap band placement and biliopancreatic diversions were excluded. All cases were done by four bariatric surgeons and by fellowship trainees under their guidance.

Our technique in creation of the gastrojejunostomy is a four layered hand sutured gastrojejunostomy sized over an 18 French nasogatric tube. We bring our roux limb up in a retro-colic retrogastric transmesocolic route. The nasogastric tube is removed after intraoperative testing of the anastamosis by injecting air through the tube while compressing the jejunum. A gastrografin upper-gastrointestinal series was also performed in all patients on the morning of postoperative day 1, and then the patient was started on a liquid diet. Care is taken to ensure that there is no tension at the anastamosis, or narrowing at the transmesocolic or jejunojejunostomy and to maintain good blood supply.

1733 cases were attempted laparoscopically in this period. We converted 3 cases from laparoscopic to open (2 due to extensive adhesions and one due to lack of working space). 81 of these gastrojejunostomy were done with Da Vinci robotic assistance while the rest were done by hand sutured technique. BMI of patients ranged from 35 to 90 kg/m2 (average BMI 47.9 kg/m2) and age from 16 to 75 years (mean 41 years). There were three mortalities in this period (one in a patient with arrythmias who threw an emboli to the small bowel, one with pulmonary embolism at about 27 days after surgery, and third with aspiration pneumonia at about 29 days). Three patients developed a leak from the staple-line in the divided gastric pouch (0.19%). During the study period, 7 patients were diagnosed with an anastomotic stricture (0.4%), and were all corrected with endoscopic dilation. Marginal ulcer and wound infection rates are both under 1%. Average length of stay was 2.7 days. 30 day readmission rate was 6.9% while 90 day readmission rate was 9.3%. Majority of the gastrojejunostomy were done by the fellows while being actively supervised by the attending surgeons.

Though technically challenging,hand sutured gastrojejunostomy seems to have excellent results and is a technique which can be learned by fellows during training under close supervision. Good results in bariatric surgery can go together with hands on teaching during the fellowship year.
 

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