Peter T. Hallowell

Should bariatric revisional surgery be avoided secondary to increased morbidity and mortality

BACKGROUND Revisional bariatric surgery may be necessary due to inadequate weight loss or postoperative complications of the primary operation. We sought to identify the reasons for revision, characteristics of the surgery, and outcomes. We hypothesize that revisional surgery, although technically challenging, can produce desirable outcomes. METHODS Patients undergoing bariatric surgery at our institution between 1998 and 2007 were reviewed from a prospective database. Patients who had revisional surgery were compared to those who had primary surgery. RESULTS We have identified 46 of 1,038 patients who underwent revisional surgery. Twenty of 46 had a primary Roux-en-Y gastric bypass. The most common indication for revisions is inadequate weight loss secondary to gastrogastric fistula (15/20). Leaks occurred more frequently following revisional surgeries (11% vs 1.2%), but intensive care unit (ICU) utilization was less (11% vs 4.4%) and mortality was lower (0% vs .3%) with bariatric revision surgery. CONCLUSIONS Although we saw a 9-fold increase in leaks, a 2-5 fold increase in ICU utilization, and 1.5-fold increase in length of stay, our mortality rate was zero. In experienced hands, bariatric revision surgery can be performed to produce desirable outcomes.

Two-Day Length of Stay following Open Roux-En-Y Gastric Bypass: is it Feasible, Safe and Reasonable?

Background: As our bariatric program matured, we noted that length of stay (LOS) steadily decreased. This led us to analyze our experience to identify factors contributing to this abbreviated LOS and to evaluate the safety of discharging patients with only a 2-day LOS. Methods: All patients undergoing open Roux-en-Y gastric bypass (RYGBP) from March, 1998 to December 31, 2002 were evaluated. Contrast swallow study was performed on Day 1. Patient demographics, complications, and readmission rates were reported for all patients. Discharge criteria included adequate oral intake, pain control with oral analgesia, and an adequate understanding of the operation and its effects demonstrated by a written test before discharge. Results: 316 patients underwent open RYGBP with mean BMI 52.3. Operative time decreased from 241 minutes in 1998 to 156 minutes in 2002. No patient was discharged at 2 days during the first 2 years of the program. In 2000, 1 of 52 patients (2%) went home on the second day. In 2001, the year we fully enacted our multidisciplinary approach, 14 of 96 patients (15%) returned home on the second day. In 2002, 73 of 145 patients (50%) were discharged on the second postoperative day, with no increase in readmission rates. Three of the 73 patients (4.1%) required readmission within 30 days of discharge. No difference in co-morbid diseases or BMI was noted between groups. Conclusions: Our data support the hypothesis that patients undergoing open RYGBP can be discharged safely at Day 2, provided that aggressive preoperative education and screening are performed.

Gastrogastric fistula following Roux-en-Y bypass is attributed to both surgical technique and experience

BACKGROUND The stomach can either be divided or undivided in performing Roux-en-Y gastric bypass (RGB) for morbid obesity. We evaluated whether surgical technique is the sole contributing factor to the formation of gastrogastric fistula (GGF). METHODS A retrospective analysis of 1,036 consecutive patients was evaluated. RGB was performed as open undivided, open divided, and laparoscopic (divided). Incidence of GGF was identified for each technique and its relationship to surgical experience was assessed. RESULTS Overall incidence of GGF was 1.3%. All fistulae occurred in patients who received undivided open RGB. There was a significant difference between the undivided open group and the divided open+laparoscopic groups (2.1% vs 0%, P<.01). Incidence of GGF decreased over time with increasing open undivided RGB volume. CONCLUSIONS GGF was only identified in undivided RGB. The occurrence decreased with increasing surgical experience. Together, overall surgical technique in addition to gastric division must play a role in fistula formation.