William Gourash

Outcomes after laparoscopic Roux-en-Y gastric bypass for morbid obesity.

ObjectiveTo evaluate the short-term outcomes for laparoscopic Roux-en-Y gastric bypass in 275 patients with a follow-up of 1 to 31 months. Summary Background DataThe Roux-en-Y gastric bypass is a highly successful approach to morbid obesity but results in significant perioperative complications. A laparoscopic approach has significant potential to reduce perioperative complications and recovery time. MethodsConsecutive patients (n = 275) who met NIH criteria for bariatric surgery were offered laparoscopic Roux-en-Y gastric bypass between July 1997 and March 2000. A 15-mL gastric pouch and a 75-cm Roux limb (150 cm for superobese) was created using five or six trocar incisions. ResultsThe conversion rate to open gastric bypass was 1%. The start of an oral diet began a mean of 1.58 days after surgery, with a median hospital stay of 2 days and return to work at 21 days. The incidence of early major and minor complications was 3.3% and 27%, respectively. One death occurred related to a pulmonary embolus (0.4%). The hernia rate was 0.7%, and wound infections requiring outpatient drainage only were uncommon (5%). Excess weight loss at 24 and 30 months was 83% and 77%, respectively. In patients with more than 1 year of follow-up, most of the comorbidities were improved or resolved, and 95% reported significant improvement in quality of life. ConclusionLaparoscopic Roux-en-Y gastric bypass is effective in achieving weight loss and in improving comorbidities and quality of life while reducing recovery time and perioperative complications.

Effect of Laparoscopic Roux-En Y Gastric Bypass on Type 2 Diabetes Mellitus

Objective: To evaluate pre- and postoperative clinical parameters associated with improvement of diabetes up to 4 years after laparoscopic Roux-en-Y gastric bypass (LRYGBP) in patients with type 2 diabetes mellitus (T2DM). Summary Background Data: The surgical treatment of morbid obesity leads to dramatic improvement in the comorbidity status of most patients with T2DM. However, little is known concerning what preoperative clinical factors are associated with postoperative long-term improvement in diabetes in the morbidly obese patient with diabetes. Methods: We evaluated pre- and postoperative data, including demographics, duration of diabetes, metabolic parameters, and clinical outcomes, in all patients with impaired fasting glucose (IFG) and type T2DM undergoing LRYGBP from July 1997 to May 2002. Results: During this 5-year period, 1160 patients underwent LRYGBP and 240 (21%) had IFG or T2DM. Follow up was possible in 191 of 240 patients (80%). There were 144 females (75%) with a mean preoperative age of 48 years (range, 26–67 years). After surgery, weight and body mass index decreased from 308 lbs and 50.1 kg/m2 to 211 lbs and 34 kg/m2 for a mean weight loss of 97 lbs and mean excess weight loss of 60%. Fasting plasma glucose and glycosylated hemoglobin concentrations returned to normal levels (83%) or markedly improved (17%) in all patients. A significant reduction in use of oral antidiabetic agents (80%) and insulin (79%) followed surgical treatment. Patients with the shortest duration (<5 years), the mildest form of T2DM (diet controlled), and the greatest weight loss after surgery were most likely to achieve complete resolution of T2DM. Conclusion: LRYGBP resulted in significant weight loss (60% percent of excess body weight loss) and resolution (83%) of T2DM. Patients with the shortest duration and mildest form of T2DM had a higher rate of T2DM resolution after surgery, suggesting that early surgical intervention is warranted to increase the likelihood of rendering patients euglycemic.

The learning curve for laparoscopic Roux-en-Y gastric bypass is 100 cases

Background: The purpose of this study was to determine the effect of operative experience on perioperative outcomes for laparoscopic Roux-en-Y gastric bypass (LGB). Methods: Between July 1997 and September 2001, 750 patients underwent LGB for the treatment of morbid obesity at our center. We evaluated the perioperative outcomes of the first 150 consecutive patients to determine if a learning curve effect could be demonstrated. The patients were divided into three groups (1, 2, and 3) of 50 consecutive patients, and outcomes for each group were compared. Results: The patients in group 3 had a larger body mass index (BMI), were more likely to have had prior abdominal surgery, and were more likely to have secondary operations at the time of LGB. Operating time decreased from a mean of 311 min in group 11 to 237 min in group 3, and technical complications were reduced by 50% after an experience of 100 cases. Conclusions: Operative time and technically related complications decreased with operative experience even though heavier patients and higher-risk patients were more predominant in the latter part of our experience. LGB is a technically challenging operation with a long learning curve. To minimize morbidity related to the learning curve, strategies for developing training programs must address these challenges.

Symptomatic improvement in gastroesophageal reflux disease (GERD) following laparoscopic Roux-en-Y gastric bypass

Background: The purpose of this study was to determine the effect of laparoscopic Roux-en-Y gastric bypass (LRYGBP) on symptomatic control of gas-troesophageal reflux disease (GERD). Methods: Morbidly obese patients (n = 435) who un-derwent LRYGBP for morbid obesity were assessed for changes in GERD symptoms, quality of life, and patient satisfaction after surgery. Results: A total of 238 patients (55%) had evidence of chronic GERD, and 152 patients (64%) voluntarily participated in the study. The mean body mass index (BMI) was 48 kg/m2. The mean excess weight loss was 68.8% at 12 months. There was a significant decrease in GERD-related symptoms, including heartburn (from 87% to 22%, p < 0.001); water brash (from 18% to 7%, p<0.05); wheezing (from 40% to 5%, p<0.001) laryngitis (from 17% to 7%, p < 0.05); and aspiration (from 14% to 2%, p<0.01) following LRYGBP. Post-operatively, the use of medication decreased significantly both for proton pump inhibitors (from 44% to 9%, p < 0.001) and for the H2 blockers (from 60% to 10%, p < 0.01). SF-36 physical function scores and the mental component summary scores improved after the operation (87 vs 71; p < 0.05 and 83 vs 66; p < 0.05, respectively). Overall patient satisfaction was 97%. Conclusion: LRYGBP results in very good control of GERD in morbidly obese patients with follow-up as late as 3 years. Morbidly obese patients who require surgery for GERD may be better served by LRYGBP than fundoplication because of the additional benefit of significant weight loss.

Laparoscopic sleeve gastrectomy for super obese patients: forty-eight percent excess weight loss after 6 to 8 years with 93% follow-up.

Objectives:In this study, we report long-term outcomes of high-risk, high-BMI (body mass index) patients who underwent laparoscopic sleeve gastrectomy (LSG). Background:Short- and medium-term data appear to support the effectiveness of LSG, but long-term data to support its durability are sparse. Methods:A prospective database was reviewed on all high-risk patients who underwent LSG as part of a staged approach for surgical treatment of severe obesity between January 2002 and February 2004. We included only patients who did not proceed to second-stage surgery (gastric bypass). Analyzed data included demographics, BMI, comorbidities, and surgical outcomes. All partial gastrectomies were performed using a 50F bougie. Results:Seventy-four patients underwent LSG, and follow-up data were available on 69 of 74 patients (93%). The mean age was 50 years (25–78) and the mean number of co-morbidities was 9.6. Perioperative mortality (<30 days) was zero, and the incidence of short- and long-term postoperative complications was 15%. The mean overall follow-up time period was 73 months (38–95). Mean excess weight loss (EWL) at 72, 84, and 96 months after LSG was 52%, 43%, and 46%, respectively, with an overall EWL of 48%. The mean BMI decreased from 66 kg/m2(43–90) to 46 kg/m2 (22–73). Seventy-seven percent of the diabetic patients showed improvement or remission of the disease. Conclusions:This study reports the longest follow-up of LSG patients thus far and supports the effectiveness, safety, and durability of laparoscopic sleeve gastrectomy as a definitive therapeutic option for severe obesity, even in high-risk, high-BMI patients.

Elective cholecystectomy during laparoscopic Roux-en-Y gastric bypass: Is it worth the wait?

Background: Combined gastric bypass and cholecystectomy have been advocated for open bariatric procedures. Our goal was to evaluate the safety of this technique in laparoscopic bariatric surgery patients with gallstones diagnosed preoperatively. Methods: 94 out of 556 consecutive morbidly obese patients (16.9%) underwent laparoscopic gastric bypass with simultaneous cholecystectomy (LGBP/LC) for cholelithiasis. Results: 328 patients (59%) had a concomitant secondary procedure, most commonly cholecystectomy (28.7%). Preoperative BMI was 48.6±6.9 kg/m2 for LGBP/LC patients and 48.8±7.3 kg/m2 (P=0.85) for LGBP alone. 5 patients had preoperative biliary colic; the others were asymptomatic for cholelithiasis. Postoperatively, at a mean follow-up of 7.6±6.7 months, the percent excess weight loss (%EWL) was 46.1±0.25 for the combined procedure vs 50.2±63.0 (P=0.55) for LGBP alone. There were no conversions to open procedures for the LC. Port placement for the LGBP was not altered for LC. None required intraoperative cholangiography. Operative time for the combined procedure was 293.4±79.8 minutes vs 244.8±77.2 minutes for LGBP alone (P<0.0001). Length of stay for the combined procedure was 4.35±10.8 days vs 2.69±1.8 days for LGBP alone (P=0.0069).There were no postoperative bile leaks or bile duct injuries. Conclusion: Concomitant LGBP/LC is safe and feasible without altering port placement. Combining these procedures significantly increases operative time and nearly doubles the hospital stay.

Selective nonoperative management of leaks after gastric bypass: Lessons learned from 2675 consecutive patients

Objective:To compare outcomes of patients with leaks after primary Roux-en-Y gastric bypass (GBP) managed operatively with those managed nonoperatively and subsequently derive indications for selective nonoperative management. Summary of Background Data:There is no consensus on the management of leaks complicating GBP, which remains the commonest cause of death. Methods:We evaluated 2675 consecutive GBP procedures, determining incidence and outcomes of leaks in a program emphasizing early detection, routine drainage, and selective nonoperative management. Results:Leaks occurred in 46 patients (41 women) with mean (±SD) age of 46.9 ± 8.7 years, weight and body mass index (BMI) of 307.8 ± 56.9 lb and 51.2 ± 9.5 kg/m2, respectively. Leaks were initially identified by upper gastrointestinal contrast swallow (UGI) on the first postoperative day (22), abnormal drain output (11), delayed UGI (3), or on clinical suspicion (10) with a respective interval to diagnosis of 1.1*, 6.5, 7, and 7.9 days (*P < 0.007 vs. other groups). Leaks were located in the gastrojejunal (GJ) anastomosis (37), gastric pouch (4), gastric remnant (2), jejuno-jejunostomy (1), Roux limb (1), and cervical esophagus (1), and were radiologically contained (40) or diffuse (3) or not demonstrable (3). Contained leaks were treated nonoperatively (31), by operation (7), or required no treatment (2). Patients with diffuse leaks or bilious drain output were operatively managed. They were similar in duration for nil per oral order, drain and antibiotic use and readmission rates, whereas hospital stays were longer in the operative group, P < 0.01. There were no deaths. Conclusions:Many leaks after gastric bypass are radiologically contained GJ and pouch leaks and can be safely managed nonoperatively. Radiologic features and bilious drainage were key determinants of treatment, with operative treatment used for diffuse GJ leaks, bilious drainage, or clinical suspicion with a negative UGI. Outcomes were similar in both groups.

Laparoscopic Gastric Bypass Surgery: Current Technique

THE TECHNIQUE OF LAPAROSCOPIC Roux-en-Y gastric bypass has evolved significantly since Wittgrove and Clark developed their technique in the early 1990s.1 Multiple variations of each key aspect of the procedure have evolved.2–8 The major steps of the procedure include patient positioning, setup and port placement, pouch creation, Roux-limb construction, jejuno-jejunostomy, and gastrojejunostomy. Table 1 lists the multiple variations of each major step along with their advantages and disadvantages. The most complex step of the procedure is the gastrojejunostomy, which correspondingly varies most from surgeon to surgeon. Our approach to the laparoscopic Roux-en-Y gastric bypass at the University of Pittsburgh has also evolved since we began our laparoscopic bariatric program in July of 1997. Our goal has been simplification of the procedure to reduce technical complications, facilitate teaching it to our fellows, residents, and visiting surgeons, and complete each case consistently within 1.5 to 2.5 hours. Our current experience as of January 2003 is approximately 2000 cases, and we have taught the procedure to more than 500 surgeons, including residents and fellows. In our first technique (cases 1–150), adapted from the method of Wittgrove and Clark, we created a retrocolic, retrogastric Roux-limb and used a circular stapler for the gastrojejunal anastomosis. The anvil was placed within the gastric pouch by passing it through the mouth with a pull wire technique. This method worked quite well, but we found that by using a linear stapler (cases 151–850) for the gastrojejunal anastomosis, as described by Champion et al.,3 we could simplify the procedure significantly. With the linear stapler, we observed a reduction (from 3% to less than 1%) in the rate of wound infections related to withdrawal of the contaminated circular stapler through the port site. We also achieved a 15to 30-minute reduction in operating time with the linear stapler. In our most recent modification (cases 851–2000), we switched from a retrocolic, retrogastric Roux-limb to an antecolic, antegastric Roux-limb, as described by Gagner et al.4 This modification has resulted in a significant reduction in the number of internal hernias caused by protrusion of the bowel through the mesocolon defect required in the retrocolic technique. Furthermore, we have not seen an increase in the number of complications resulting from the increased tension at the gastrojejunal anastomosis that is required with an antecolic Roux-limb. Thus, our current technique, which we describe and illustrate in this article, involves the following: a 15-mL gastric pouch; a two-layer gastrojejunal anastomosis (sutured outer layer and stapled inner layer); an antecolic, antegastric Rouxlimb; and an end-side (stapled) jejuno-jejunostomy.

Sexual functioning and sex hormones in persons with extreme obesity and seeking surgical and nonsurgical weight loss

BACKGROUND Many individuals with obesity are motivated to lose weight to improve weight-related co-morbidities or psychosocial functioning, including sexual functioning. Few studies have documented rates of sexual dysfunction in persons with obesity. This study investigated sexual functioning, sex hormones, and relevant psychosocial constructs in individuals with obesity who sought surgical and nonsurgical weight loss. METHODS One hundred forty-one bariatric surgery patients (median BMI [25th percentile, 75th percentile] 44.6 [41.4, 50.1]) and 109 individuals (BMI = 40.0 [38.0, 44.0]) who sought nonsurgical weight loss participated. Sexual functioning was assessed by the Female Sexual Function Index (FSFI) and the International Index of Erectile Function (IIEF). Hormones were assessed by blood assay. Quality of life, body image, depressive symptoms, and marital adjustment were assessed by validated questionnaires. RESULTS Fifty-one percent of women presenting for bariatric surgery reported a sexual dysfunction; 36% of men presenting for bariatric surgery reported erectile dysfunction (ED). This is in contrast to 41% of women who sought nonsurgical weight loss and reported a sexual dysfunction and 20% of men who sought nonsurgical weight loss and reported ED. These differences were not statistically significant. Sexual dysfunction was strongly associated with psychosocial distress in women; these relationships were less strong and less consistent among men. Sexual dysfunction was unrelated to sex hormones, except for sex hormone binding globulin (SHGB) in women. CONCLUSION Women and men who present for bariatric surgery, compared with individuals who sought nonsurgical weight loss, were not significantly more likely to experience a sexual dysfunction. There were few differences in reproductive hormones and psychosocial constructs between candidates for bariatric surgery and individuals interested in nonsurgical weight loss.

Longitudinal Assessment of Bariatric Surgery (LABS): Retention strategy and results at 24 months

BACKGROUND Retaining participants in observational longitudinal studies after bariatric surgery is difficult yet critical because the retention rate affects interpretation and generalizability of results. Strategies for keeping participants involved in such studies are not commonly published. The objective of this study was to review LABS retention strategies and present the 24-month retention data. METHODS The LABS Consortium monitors an observational cohort study of 2458 adults enrolled before bariatric surgery at 10 centers within the United States (LABS-2). To maximize data completeness, the investigators developed retention strategies, including flexible scheduling, a call protocol, reminder letters, abbreviated visit options, honoraria, travel reimbursement, providing research progress reports, laboratory results, newsletters, study website, and retention surveys. Strategies for locating participants included frequent updates of contact information, sending registered letters, and searching medical and public records. RESULTS At 12 and 24 months, 2426 and 2405 participants remained active, with vital status known for 98.7% and 97.3% and weight obtained for 95.2% and 92.2%, respectively. There were 148 missed visits (6.2%) at 24 months primarily because of inability to contact the participant. Only 15 (0.6%) active participants at 24 months missed all follow-up visits. Although 42 participants could not be located or contacted at 6 months, data were obtained for 23 (54.7%) of them at 12 months, and of the 52 participants who could not be located or contacted at 12 months, data were obtained for 18 (34.6%) at 24 months. CONCLUSION Longitudinal studies provide the ability to evaluate long-term effects of bariatric surgical procedures. The retention achieved in LABS is superior to that of many published reports but requires extensive effort and resources. This report identifies useful retention strategies. Further research is needed to identify the efficacy and cost-effectiveness of specific retention strategies.