Jill G. Meador

Results of 281 Consecutive Total Laparoscopic Roux-en-Y Gastric Bypasses to Treat Morbid Obesity

ObjectiveTo determine the safety and efficacy of laparoscopic Roux-en-Y gastric bypass for the treatment of morbid obesity. Summary Background DataLaparoscopic Roux-en-Y gastric bypass is a new and technically challenging surgical procedure that requires careful study. MethodsThe authors attempted total laparoscopic Roux-en-Y gastric bypass in 281 consecutive patients. Procedures included 175 proximal bypasses, 12 long-limb bypasses, and 9 revisional procedures from previous bariatric operations. The gastrojejunostomy and jejunojejunostomy were primarily constructed using linear stapling techniques. ResultsEight patients required conversion to an open procedure (2.8%). The mean age of the patients was 41.6 years (range 15–71) and 87% were female. The mean preoperative body mass index was 48.1 kg/m2. The operative time decreased significantly from 234 ± 77 minutes in the first quartile to 162 ± 42 minutes in the most recent quartile. Postoperative length of stay averaged 4 days (range 2–91), with 75% of patients discharged within 3 days. The median hospital stay was 2 days. No patient died after surgery. Complications included three (1.5%) major wound infections (each followed a reoperation for a complication or open conversion), incisional hernia in 5 patients (1.8%), and anastomotic leak with peritonitis in 14 patients (5.1%). Three gastrojejunal leaks were managed without surgery, four by laparoscopic repair/drainage, and three by open repair/drainage. Only three patients had anastomotic leaks in the most recent 164 procedures (1.8%) since the routine use of a two-layer anastomotic technique. Data at 1 year after surgery were available in 69 of 96 (72%) patients (excludes revisions). Weight loss at one year was 70 ± 5% of excess weight. Most comorbid conditions resolved by 1 year after surgery; notably, 88% of patients with diabetes no longer required medications. ConclusionsLaparoscopic gastric bypass demonstrates excellent weight loss and resolution of comorbidities with a low complication rate. The learning curve is evident: operative time and leaks decreased with experience and improved techniques. The primary advantage is an extremely low risk of wound complications, including infection and hernia.

High Failure Rate After Laparoscopic Adjustable Silicone Gastric Banding for Treatment of Morbid Obesity

ObjectiveTo report the results from one of the eight original U.S. centers performing laparoscopic adjustable silicone gastric banding (LASGB), a new minimally invasive surgical technique for treatment of morbid obesity. Summary Background DataLaparoscopic adjustable silicone gastric banding is under evaluation by the Food & Drug Administration in the United States in an initial cohort of 300 patients. MethodsOf 37 patients undergoing laparoscopic placement of the LASGB device, successful placement occurred in 36 from March 1996 to May 1998. Patients have been followed up for up to 4 years. ResultsFive patients (14%) have been lost to follow-up for more than 2 years but at last available follow-up (3–18 months after surgery) had achieved only 18% (range 5–38%) excess weight loss. African American patients had poor weight loss after LASGB compared with whites. The LASGB devices were removed in 15 (41%) patients 10 days to 42 months after surgery. Four patients underwent simple removal; 11 were converted to gastric bypass. The most common reason for removal was inadequate weight loss in the presence of a functioning band. The primary reasons for removal in others were infection, leakage from the inflatable silicone ring causing inadequate weight loss, or band slippage. The patients with band slippage had concomitant poor weight loss. Bands were removed in two others as a result of symptoms related to esophageal dilatation. In 18 of 25 patients (71%) who underwent preoperative and long-term postoperative contrast evaluation, a significantly increased esophageal diameter developed; of these, 13 (72%) had prominent dysphagia, vomiting, or reflux symptoms. Of the remaining 21 patients with bands, 8 currently desire removal and conversion to gastric bypass for inadequate weight loss. Six of the remaining patients have persistent morbid obesity at least 2 years after surgery but refuse to undergo further surgery or claim to be satisfied with the results. Overall, only four patients achieved a body-mass index of less than 35 and/or at least a 50% reduction in excess weight. Thus, the overall need for band removal and conversion to GBP in this series will ultimately exceed 50%. ConclusionsThe authors did not find LASGB to be an effective procedure for the surgical treatment of morbid obesity. Complications after LASGB include esophageal dilatation, band leakage, infection, erosion, and slippage. Inadequate weight loss is common, particularly in African American patients. More study is required to determine the long-term efficacy of the LASGB

Multivariate Analysis of Risk Factors for Death Following Gastric Bypass for Treatment of Morbid Obesity

Objective:To identify the factors that increase mortality for either open or laparoscopic Roux-en-Y gastric bypass. Summary Background Data:Perioperative mortality is the most feared outcome of bariatric surgery, reported to occur in between 0.5% and 1.5% of patients. Methods:The bariatric database at Virginia Commonwealth University was queried for patients who had undergone either an open gastric bypass (O-GBP) or a laparoscopic gastric bypass (L-GBP). A multivariate logistic regression analysis to identify factors related to perioperative mortality was performed. Factors examined included age, gender, body mass index, preoperative weight, hypertension, diabetes mellitus, sleep apnea, obesity hypoventilation syndrome, venous stasis ulcers, intestinal leak, small bowel obstruction, and pulmonary embolus. Results:Since 1992, more than 2000 patients had either an O-GBP (n = 1431) or a L-GBP (n = 580). Of the O-GBP, 547 patients had a proximal GBP (P-GBP) and 884 superobese (body mass index > 50 kg/m2) patients had a long-limb GBP (LL-GBP). The differences in patient demographics, complications, and perioperative mortality rates between L-GBP and O-GBP and P-GBP and LL-GBP patients were examined. Overall, the independent risk factors associated with perioperative death included leak, pulmonary embolus, preoperative weight, and hypertension. Conclusions:The risk factors for perioperative death can be separated into patient characteristics and complications. The access method, open versus laparoscopic, was not independently predictive of death, but the operation type, proximal versus long limb, was predictive. The data do not suggest that superobese patients should not undergo surgery, as they are high risk for early death due to their body weight and comorbidities without surgery. Surgery should not be reserved as a desperate last measure for weight loss.

Experience with over 3,000 open and laparoscopic bariatric procedures: Multivariate analysis of factors related to leak and resultant mortality

Background: Intestinal leak is a potentially lethal complication of Roux en-Y gastric bypass (GBP). Identification of patients at high risk for leak may reduce complication rates of surgeons early in the procedure learning curve. Methods: A total of 3073 patients who underwent GBP were analyzed using univariate and multivariate logistic regression analyses of the following preoperative factors: hypertension (HTN), diabetes mellitus (DM), sleep apnea (SA), age, gender, weight, body mass index (BMI), and surgery type. Multivariate logistic regression analysis was performed for each procedure type. Results: There were 48 (1.5%) deaths. Independent risk factors for death included leak, weight, procedure type, and HTN. A total of 102 (3.2%) leaks were found. Independent factors for leak included age, male gender, SA, and procedure type. Conclusion: The data suggests that older, heavier male patients with multiple comorbid conditions are at increased risk for leak and mortality. Surgeons early in their learning curve should avoid these high-risk patients to reduce complications.

Analysis of factors associated with durable remission of diabetes after Roux-en-Y gastric bypass

BACKGROUND Data on the durability of remission of type 2 diabetes mellitus (T2DM) after gastric bypass are limited. Our purpose was to identify the rate of long-term remission of T2DM and the factors associated with durable remission. METHODS A total of 177 patients with T2DM who had undergone Roux-en-Y gastric bypass from 1993 to 2003 had 5-year follow-up data available. T2DM status was determined by interview and evaluation of the diabetic medications. Patients with complete remission or recurrence of T2DM were identified. RESULTS Follow-up ranged from 5 to 16 years. Of the 177 patients, 157 (89%) had complete remission of T2DM with a decrease in their mean body mass index from baseline (50.2 +/- 8.2 kg/m(2)) to 31.3 +/- 7.2 kg/m(2) postoperatively (mean percentage of excess weight loss 70.0% +/- 18.6%). However, 20 patients (11.3%) did not have T2DM remission despite a mean percentage of excess weight loss of 58.2% +/- 12.3% (P <.0009). Of the 157 patients with initial remission of their T2DM, 68 (43%) subsequently developed T2DM recurrence. Remission of T2DM was durable in 56.9%. Durable (>5-year) resolution of T2DM was greatest in the patients who originally had either controlled their T2DM with diet (76%) or oral hypoglycemic agents (66%). The rate of T2DM remission was more likely to be durable in men (P = .00381). Weight regain was a statistically significant, but weak predictor, of T2DM recurrence. CONCLUSION Early remission of T2DM occurred in 89% of patients after Roux-en-Y gastric bypass. T2DM recurred in 43.1%. Durable remission correlated most closely with an early disease stage at gastric bypass.

Effects of Bariatric surgery in older patients

Objective:Evaluate the safety and efficacy of bariatric surgery in older patients. Background:Because of an increased morbidity in older patients who may not be as active as younger individuals, there remain concerns that they may not tolerate the operation well or lose adequate amounts of weight. Methods:The database of patients who had undergone bariatric surgery since 1980 and National Death Index were queried for patients <60 and ≥ 60 years of age. GBP was the procedure of choice after 1985. Data evaluated at 1 and 5 years included weight lost, % weight lost (%WL), % excess weight loss (%EWL), % ideal body weight (%IBW), mortality, complications, and obesity comorbidity. Results:Eighty patients underwent bariatric surgery: age 63 ± 3 years, 78% women, 68 white, 132 ± 22 kg, BMI 49 ± 7 kg/m2, 217 ± 32%IBW. Preoperative comorbidity, was greater (P < 0.001) in patients ≥ 60 years. There were no operative deaths but 11 late deaths. Complications: 4 major wound infections, 2 anastomotic leaks, 10 symptomatic marginal ulcers, 5 stomal stenoses, 3 bowel obstructions, 26 incisional hernias (nonlaparoscopic), and 1 pulmonary embolism. At 1 year after surgery (94% follow-up), patients lost 38 ± 11 kg, 57%EWL, 30%WL, BMI 34.5 ± 7 kg/m2, %IBW 153 ± 31. Comorbidities decreased (P < 0.001); however, %WL and %EWL and improvement in hypertension and orthopedic problems, although significant, were greater in younger patients. At 5 years after surgery (58% follow-up), they had lost 31 ± 18 kg, 50%EWL, 26%WL, BMI 35 ± 8 kg/m2, and %IBW 156 ± 36. Conclusions:Bariatric surgery was effective for older patients with a low morbidity and mortality. Older patients had more pre- and post-operative comorbidities and lost less weight than younger patients. However the weight loss and improvement in comorbidities in older patients were clinically significant.

Becoming Physically Active After Bariatric Surgery is Associated With Improved Weight Loss and Health-related Quality of Life

The purpose of this study was to determine whether pre‐ to postoperative increases in physical activity (PA) are associated with weight loss and health‐related quality of life (HRQoL) following bariatric surgery. Participants were 199 Roux‐en‐Y gastric bypass (RYGB) surgery patients. The International Physical Activity Questionnaire (IPAQ) was used to categorize participants into three groups according to their preoperative and /1‐year postoperative PA level: (i) Inactive/Active (<200‐min/week/≥200‐min/week), (ii) Active/Active (≥200‐min/week/≥200‐min/week) and (iii) Inactive/Inactive (<200‐min/week/<200‐min/week). The Medical Outcomes Study Short Form‐36 (SF‐36) was used to assess HRQoL. Analyses of covariance were conducted to examine the effects of PA group on weight and HRQoL changes. Inactive/Active participants, compared with Inactive/Inactive individuals, had greater reductions in weight (52.5 ± 15.4 vs. 46.4 ± 12.8 kg) and BMI (18.9 ± 4.6 vs. 16.9 ± 4.2 kg/m2). Weight loss outcomes in the Inactive/Active and Active/Active groups were similar to each other. Inactive/Active and Active/Active participants reported greater improvements than Inactive/Inactive participants on the mental component summary (MCS) score and the general health, vitality and mental health domains (P < 0.01). Although the direction of causation is not clear, these findings suggest that RYGB patients who become active postoperatively achieve weight losses and HRQoL improvements that are greater than those experienced by patients who remain inactive and comparable to those attained by patients who stay active. Future randomized controlled trials should examine whether assisting patients who are inactive preoperatively to increase their PA postoperatively contributes to optimization of weight loss and HRQoL outcomes.

Ileal Pouch Anal Anastomosis Without Ileal Diversion

ObjectiveTo evaluate continued experience with a one-stage stapled ileoanal pouch procedure without temporary ileostomy diversion. Summary Background DataMost centers perform colectomy, proctectomy, and ileal pouch anal anastomoses (IPAA) with a protective ileostomy. Following a previous report, the authors performed 126 additional stapled IPAA procedures for ulcerative colitis and familial adenomatous polyposis, of which all but 2 were without an ileostomy. Outcomes in these patients question the need for temporary ileal diversion, with its complications and need for subsequent surgical closure. MethodsTwo hundred one patients underwent a stapled IPAA since May 1989, 192 as a one-stage procedure without ileostomy, and 1 with a concurrent Whipple procedure for duodenal adenocarcinoma. Patient charts were reviewed or patients were contacted by phone to evaluate their clinical status at least 1 year after their surgery. ResultsAmong the patients who underwent the one-stage procedure, 178 had ulcerative colitis (38 fulminant), 5 had Crohn’s disease (diagnosed after IPAA), 1 had indeterminate colitis, and 8 had familial adenomatous polyposis. The mean age was 38 ± 7 (range 7–-70) years; there were 98 male patients and 94 female patients. The average amount of diseased tissue between the dentate line and the anastomosis was 0.9 ± 0.1 cm, with 35% of the anastomoses at the dentate line. With 89% follow-up at 1 year or more (mean 5.1 ± 2.4 years) after surgery, the average 24-hour stool frequency was 7.1 ± 3.3, of which 0.9 ± 1.4 were at night. Daytime stool control was 95% and night-time control was 90%. Only 2.3% needed to wear a perineal pad. Average length of hospital stay was 10 ± 0.3 days, with 1.5 ± 0.5 days readmission for complications. Abscesses or enteric leaks occurred in 23 patients; IPAA function was excellent in 19 of these patients (2 have permanent ileostomies). In patients taking steroids, there was no significant difference in leak rate with duration of use (29 ± 8 with vs. 22 ± 2 months without leak) or dose (32 ± 13 mg with vs. 35 ± 3 mg without leak). Two (1%) patients died (myocardial infarction, mesenteric infarction). ConclusionsThe triple-stapled IPAA without temporary ileal diversion has a relatively low complication rate and a low rate of small bowel obstruction, provides excellent fecal control, permits an early return to a functional life, and can be performed in morbidly obese and older patients.

Postoperative complications are not increased in super-super obese patients who undergo laparoscopic Roux-en-Y gastric bypass

BackgroundIt has been suggested that super-super obesity (body mass index [BMI] ≥60 kg/m2) increases the risk of complications after laparoscopic Roux-en-Y gastric bypass (LapRYGB). We hypothesized that a higher BMI does not increase risk the morbidity or mortality rate.MethodsComplication rates for patients with a BMI ≥60 kg/m2 were compared to those for patients with a BMI <60 kg/m2 who underwent LapRYGB during the same time period. Differences between the groups were analyzed by Fisher’s exact test, t-tests, and analysis of variance.ResultsForty-five patients with a BMI ≥60 kg/m2 and 640 patients with a BMI <60 kg/m2 underwent LapRYGB. There were no statistically significant differences between the two groups in the complication or mortality rates. Excess weight loss was less, but actual weight lost was greater in the BMI ≥60 kg/m2 group.ConclusionsThe complication and mortality rates are not increased in super-super obese patients who undergo LapRYGB. Acceptable weight loss can be achieved safely in these patients.

Four Hundred Fifty Consecutive Laparoscopic Roux-en-Y Gastric Bypasses with No Mortality and Declining Leak Rates and Lengths of Stay in a Bariatric Training Program

BACKGROUND We reviewed our obesity surgery database for 2 experienced bariatric surgeons since their last patient death in October 2003 through July 2007. STUDY DESIGN Data on all patients undergoing planned laparoscopic Roux-en-Y gastric bypass (L-GBP) by the two attending bariatric surgeons at the Medical College of Virginia Hospitals were reviewed. The operations were performed by fellows in minimally invasive surgery, assisted by the 2 attending physicians in more than 90% of patients. Surgical technique included a handsewn imbrication of a gastrojejejunostomy and jejunojejunostomy, each performed with a linear stapler. Routine sampling of a juxtaanastamotic drain for amylase levels was substituted for routine upper gastrointestinal contrast studies during the study period. RESULTS All patients, except those who had earlier extensive upper abdominal surgery in that time period, were offered a laparoscopic approach (5.7% were converted to open procedures). The mean (+/- SD) age was 42.4+/-11 years; body mass index was 49.5+/-9 kg/m(2). Women represented 80.5% of patients. The leak rate declined from 9.7% in 2004 to 2.0% in 2006 (p < 0.05, chi-square test); there have been no leaks in any patient since July 2006, including the 40 patients in 2007. Hospital length of stay declined from 4.7+/-5.7 days in 2004 to 2.9+/-3.3 days in 2006 (p < 0.05, Wilcoxon rank test). At 1-year followup, 270 patients had lost 66.1%+/-17% of initial excess weight, which was similar to that in our open gastric bypasses. Comorbid conditions improved or resolved in 67.6% of patients with diabetes, 56.1% of those with hypertension, 75% of those with sleep apnea, 87.8% of those with urinary stress incontinence, 95.9% of those with gastroesophageal reflux disease, and in 100% of those with stasis ulcers. Overall complication rates of wound infection (1.5%), incisional hernia (1.7%), internal hernia (0.2%), and intestinal obstruction (1.7%) were low. CONCLUSIONS Results for laparoscopic Roux-en-Y gastric bypass improve with experience and can be taught in an academic training program, with low morbidity and mortality. Routine postoperative upper gastrointestinal contrast studies are unnecessary and may lengthen hospital stay.