Laparoscopic versus Open Procedures
The procedures in this section will be described using a laparoscopic approach as the default or typical approach. RYGB, BPD, and DS may still be performed by some surgeons using an open approach, but this has now become the exception. Minimization of the morbidity of the open incision, especially incisional hernias and wound complications, as well as earlier hospital discharge and lower 30-day complication rates have all been clearly shown to favor using a laparoscopic approach when feasible.52,53,54 In addition, the logical assumption that avoiding the major tissue trauma associated with a lengthy abdominal wall incision is beneficial to patient recovery has been confirmed. Most importantly, patient interest in bariatric surgery increased dramatically once a laparoscopic approach was available for these procedures, especially RYGB.55 In the twenty-first century, most prospective bariatric patients are informed enough about the options for surgery that they seek out a surgeon who does laparoscopic bariatric surgery.
When an open surgical approach is used for any of these procedures, an upper midline incision is the most commonly used approach. Some surgeons have had excellent success with a left subcostal incision for performing RYGB.56 Mechanical retractors afford additional exposure for open surgery and are indicated. Wound closure for midline incisions usually is performed using heavy monofilament suture for the midline fascia, but surgeon preferences vary. Any concerning drainage from a postoperative open surgical incision line requires opening of the wound in that area and confirmation that a more severe deep-seated fascial tissue infection does not exist.
Laparoscopic surgery requires a basic core set of knowledge and skills that have now become a standard part of surgical training. Successful completion of the Fundamentals of Laparoscopic Surgery (FLS) unit developed by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES)57 is now mandatory for all surgical residents in the United States.
Laparoscopy begins with the safe creation of a pneumoperitoneum, often a difficult step in the bariatric patient. We have found the use of a tracheostomy hook inserted through a trocar-sized incision to elevate the fascia in the left subcostal region to be of great assistance in facilitating the insertion of a Veress needle into an appropriate location for pneumoperitoneum creation. In general, the use of a Hasson approach for creating a pneumoperitoneum in the bariatric population is limited by the thick body wall. In the patient with an extremely thick body wall, extra long trocar ports can be used for laparoscopic surgery.
The pneumoperitoneum pressure that is used when performing bariatric surgical procedures is generally in the 15 to 18 mmHg range. A high-flow insufflator is mandatory to maintain the pneumoperitoneum for adequate and safe visualization. An angled telescope is quite helpful. Instrumentation for performing laparoscopic bariatric surgery has dramatically improved in the past 15 years and continues to improve. We now favor using certain laparoscopic instruments, such as the staplers and harmonic scalpel, even if conversion to an open approach occurs.
Conversion to an open incision is appropriate in circumstances where patient safety would potentially be compromised by persisting with a laparoscopic approach. Table 27-5 lists appropriate reasons for conversion to an open incision as well as consideration for beginning with open surgery if certain conditions are known, such as an existing large upper abdominal incisional hernia or known severe intra-abdominal adhesions. Conversion to an open incision should not be viewed as a failure by the surgeon, nor should such an attitude bias the surgeon in favor of persisting with a laparoscopic approach if the operation is not progressing or if a complication is worsening when it could be corrected more quickly using an open approach. Patient safety is the gold standard for determining the timing and appropriateness of conversion. Usually, if conversion is needed, it is best to do so as early in the course of the operation as possible.
Table 27-5Indications for conversion from laparoscopic to open surgery ||Download (.pdf) Table 27-5 Indications for conversion from laparoscopic to open surgery
1. Failure to establish an adequate pneumoperitoneum
2. Hemodynamic adverse reaction to pneumoperitoneum
3. Intra-abdominal adhesions precluding safe access or presenting excessive difficulty to access abdomen
4. Hepatomegaly such that retraction is not feasible or, even with retraction, organ visualization is obscured
5. Intraoperative complications such as hemorrhage that are best managed with an open approach
6. Exceedingly thick body wall precluding adequate trocar access or manipulation
7. Existing large upper abdominal wall hernia that optimally can be repaired simultaneously using the same incision
Short-term follow-up is defined as follow-up of up to 2 years. Unfortunately, even in the best of practices in the United States, because of the lack of a centralized health system or registry, 1-year follow-up of 90% or greater is a laudable achievement and rarely reported in most case series. Recommendations for bariatric centers wishing to be COEs are that 75% of patients are followed for 5 years with restrictive operations, and 90% are followed if they have malabsorptive operations. Those recommendations, however, are based on having a system that attempts maximum possible follow-up that should yield such results. Although a system may be in place that generates multiple attempts at having the patient return for postoperative checkups, without patient compliance, all such systems are fallible.
The goals of short-term follow-up are to maximize care of the patient in the postoperative period; assist in adjustment to new eating, exercise, and lifestyle patterns; be on the alert for and treat postoperative complications; and recommend measures to limit such complications. Objective data that should be obtained after all bariatric operations include weight loss, change in BMI, resolution or improvement in medical comorbidities, and any adverse events or complications that occur. Optimally, assessment of quality of life can help gauge efficacy as well, with the Short Form-36 (SF36) questionnaire being one standard, frequently used example. Short-term follow-up data do give a good reflection of the safety of the procedure, but only an estimate of the efficacy regarding weight loss and effect on resolution of medical comorbidities.
Medium-term follow-up is defined as that from 2 to 5 years. Medium- and long-term follow-up, defined as greater than 5 years, are the only means by which the true long-term efficacy of bariatric surgical operations can be assessed. Operations that initially appear quite promising, such as the VBG or even the jejunoileal bypass, were shown with long- and medium-term follow-up, respectively, to have significant deficiencies in efficacy for the VBG23 and safety25 for the jejunoileal bypass. Other stapled gastroplasties similarly did not demonstrate efficacy on medium-term follow-up.25
Unfortunately, to date, there has been no conventional method of reporting outcomes after bariatric surgery. The ideal publication includes quantitation of number of patients, a description of the operative technique, incidence of conversion to open if applicable, number of patients included in follow-up data per year, percentage of patients lost to follow-up, weight loss usually expressed as percentage of excess weight, initial and subsequent BMI, complications, mortality, resolution of medical comorbidities, and any quality of life data. Few publications have met these criteria. There are also only a few studies in which a prospective randomized comparison either between bariatric surgery and medical management or between different bariatric surgical operations or approaches (laparoscopic vs. open) have been performed. Improvement in study design and more complete data in future publications are indicated.
A multidisciplinary team approach to follow-up is as essential, if not more so, postoperatively than preoperatively. Regular counseling sessions with the nutritionist are always helpful. Psychological support should be available as needed to assist the patient in adjustment to major life changes. All programs should offer a frequent support group forum for patients to discuss issues on a less formal basis and receive encouragement from other patients as well as staff.
Experience of performing bariatric surgery for several decades between the co-authors has led us to conclude that whatever the operation performed, its long-term success is only achieved by patients if they embrace the eating and lifestyle changes the operation allows them to adopt. Continuation of exercise as part of the daily lifestyle is associated with a high incidence of preservation of weight loss. Diligence to avoid snacking and returning to other poor eating habits is also important. The majority of patients do embrace the metamorphosis their bariatric operation produces such that they maintain their new eating, lifestyle, and exercise habits to the benefit of their continued improved health, self-image, and well-being.
Laparoscopic Adjustable Gastric Banding
LAGB involves placement of an inflatable silicone band around the proximal stomach. The band is attached to a reservoir system that allows adjustment of the tightness of the band. This reservoir system is accessed through a subcutaneously placed port, similar in concept to ports used for chemotherapy via central venous catheters. Figure 27-2 shows the LAGB apparatus in place.
Laparoscopic adjustable band overall scheme. (From Schauer PR, et al, eds. Minimally Invasive Bariatric Surgery, 1st ed. New York: Springer; 2007. Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2005-2009. All rights reserved.)
Two major types of bands have been used for this procedure. The original Lap-Band, most recently marketed by Apollo Endosurgery, has been used most frequently. The Swedish Band, now remarketed as the Realize Band by Ethicon, is slightly wider than the Lap-Band.58 The port systems have differences as to profile and methods of attachment to the fascia.
Port placement for LAGB has varied among surgeons. Figure 27-2 shows a common configuration used. Usually some combination of two ports for the surgeon’s hands, one or two for the assistant, a port for the telescope, and a liver retractor site are needed.
With the patient placed in reverse Trendelenburg position, the procedure begins with division of the peritoneum at the angle of His and then division of the gastrohepatic ligament in its avascular area (the pars flaccida) to expose the base of the right crus of the diaphragm. If a hiatal hernia is present, it must be repaired at this point, using a standard posterior esophageal dissection to expose the crura and perform suture repair. A grasper (Lap-Band) or specially devised instrument (Realize Band) is inserted along the base of the anterior surface of the diaphragmatic crura, from right to left, emerging at the angle of His in the area of the divided peritoneum (Fig. 27-3). The device is then used to pull the band underneath the posterior surface of the gastroesophageal junction. This technique, by passing the band through some fibrous tissue in this plane, serves to anchor the band more securely posteriorly. During the initial years of band placement, a retrogastric location of the posterior half of the band in the free space of the lesser sac caused an unacceptably high incidence of slippage and prolapse of the band. The adoption of the pars flaccida technique decreased the incidence of such slippage.59
Grasper being passed through under stomach to grasp tubing during placement. (From Schauer PR, et al, eds. Minimally Invasive Bariatric Surgery, 1st ed. New York: Springer; 2007. Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2005-2009. All rights reserved.)
Once the band is passed around the proximal stomach, it is locked into its ring configuration through its own self-locking mechanism. This involves the tubing end being passed through the orifice of the buckle for the Lap-Band and the suture on the end of the flanged end of the band site being passed through for the Realize Band. Once the band is securely locked in place, the buckle portion of the band is located on the lesser curvature of the stomach (Fig. 27-4A,B). Now the anterior surface of the fundus and proximal stomach is imbricated over the band using several sutures (Fig. 27-5).
A. Lap-Band in place around stomach. (From Schauer PR, et al, eds. Minimally Invasive Bariatric Surgery, 1st ed. New York: Springer; 2007. Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2005-2009. All rights reserved. B. Realize (Swedish) Band around stomach.
Stomach imbricated over band.
The tubing of the band system is brought out through the desired site for placement of the port portion of the system. Usually this is a trocar site near the upper abdomen or xiphoid region to place the port most superficially such that it can be palpated postoperatively. The port is secured to the anterior abdominal wall fascia. Access to the port for subsequent addition of fluid to the band system is percutaneously achieved using a Huber or noncutting type needle. The band is initially placed empty of fluid in most circumstances.
Patient Selection and Preparation
Most LAGB procedures are done on an outpatient basis. Technically the operation is not as difficult as the other operations described later. Because the gastrointestinal tract is not violated, the relative risk of the procedure is lower than most other bariatric operations, making this procedure more amenable to offer to older, more medically ill, or higher risk patient populations. However, efficacy of the operation in the superobese (BMI >50 kg/m2) is less impressive, with average BMI remaining over 40 kg/m2 after 5 to 8 years of follow-up.60 It has been our impression that optimal results occur with this operation in a patient population who is motivated, needs to lose less than 50 kg to achieve a BMI less than 30 kg/m2, is willing and able to exercise regularly, is amenable to changing eating patterns as recommended, and is within a geographically close enough area for ease of follow-up. Patients who are impatient to lose weight, immobile, unable or unwilling to exercise, or confirmed “grazers” or “nibblers” on high-calorie sweets who expect to be able to continue their dietary habits without great alteration are not good candidates for this operation. Similarly, patients who have had previous upper gastric surgery, such as a Nissen fundoplication, are relatively poor candidates for LAGB due to the potential tissue compromise in taking down the wrap to place the band.
Important points of preoperative preparation specific to the procedure include being nil per os (NPO), receiving preoperative appropriate venous thromboembolism prophylaxis, appropriate broad-spectrum intravenous antibiotics, and having appropriate intravenous access and monitoring. An orogastric tube is inserted into the stomach. These preoperative measures are recommended in all the procedures described later as well.
Postoperative Care and Follow-Up
The majority of LAGB procedures are performed on an outpatient basis. Insurance requirement and pre-existing medical issues are usually the only reason for overnight hospitalization. Diet instructions, wound care, pain medications, and instructions on time schedule of resuming other preoperative medications should all be explained to the patient as well as to a family member (who has not just undergone general anesthesia) prior to discharge. Arrangements for a postoperative follow-up visit, phone numbers to call for emergencies, and indications to call should all be explained as well.
The first postoperative evaluation after LAGB generally occurs 2 to 3 weeks after surgery. By this time, patients have begun to tire of the blenderized diet recommended, are often eager to return to work if they have not done so, and are amenable to discussions of an exercise plan and diet progression plan. Wounds are assessed, as are medical problems, oral intake, and adherence to diet. Since LAGB does not preclude absorption of any specific nutrients, we only recommend a multivitamin for patients whose preoperative lab values are normal. Use of ursodiol (300 mg twice a day) for gallstone prophylaxis after LAGB is variable from surgeon to surgeon. Weight loss after LAGB often does not occur as rapidly as after gastric bypass, and data regarding gallstone formation after LAGB are lacking. However, rapid weight loss after LAGB will occur in some patients justifying prophylaxis with ursodiol.
Band adjustments and postoperative support group sessions are extremely important for good outcomes after LAGB.61 Band adjustments are paramount as part of the operation. The actual performance of the LAGB procedure is really only a small part of the care of the patient. Frequent postoperative visits, band adjustments as necessary, and participation in an appropriate exercise program are all important for postoperative success for these patients. Recommendations for timing of band adjustments vary from practice to practice. In general, there is agreement that losing less than 2 lb per week is an indication to increase the restriction of the band by adding fluid. Patients who can easily eat most solid foods and have little satiety and a fairly pronounced appetite need additional restriction from the band.
Band fills usually are accomplished in the outpatient clinic setting. Occasionally fluoroscopic radiology is needed to assist in accessing the port, based on the depth of the port from the skin and its ease of palpation. Experience by the person doing the band fill is an important factor in increasing the percentage of patients able to be accessed in clinic without radiology assistance. A careful record should be maintained of the amount of fluid in each patient’s band. Some surgeons will withdraw all the fluid at each fill, reinserting the desired amount. Many will just add additional fluid as indicated. The amount of fluid added is based on hunger, weight loss, and ability to eat meat or bread. Figure 27-6 shows an in-office algorithm adjustment scheme used by Ren and colleagues at New York University.62 Ideally, adjustments are performed over approximately a 2-year period after surgery. However, changing life and clinical circumstances can require adjustments at any time thereafter.
Algorithm for postoperative band adjustment. RTC = return to clinic. (Reproduced with permission from Ren CJ. Laparoscopic adjustable gastric banding: postoperative management and nutritional evaluation. In: Schauer PR, et al, eds. Minimally Invasive Bariatric Surgery. 1st ed. New York: Springer; 2007:200. With kind permission of Springer Science + Business Media.)
An optimal situation for LAGB success is a program whose patients all live within an easy drive of the center, will and do participate in frequently available support groups and use exercise facilities supplied by the program, have access to band adjustment visits as needed, and are carefully selected for appropriateness and motivation for the procedure preoperatively.
Medium- to long-term (8-year follow-up) outcomes have been reported for LAGB from Weiner et al.63 At 5 and 7 years after LAGB, an average of published studies in the literature showed that patients lost 60% and 58% of excess weight, respectively.64 Resolution of comorbidities after LAGB has been reported as overall very good, with hypertension resolving in 55% at 1 year,64 observed sleep apnea decreasing from 33% to 2%,65 GERD improving in over 50% of cases,66 and asthma,67 depression,68 and quality of life69 improving for patients after LAGB. Dixon and colleagues70 published a landmark article describing the vastly superior results of managing patients with diabetes using LAGB versus optimal medical management. Resolution of diabetes was 13% in the medical group versus 73% in the surgical group after a 2-year follow-up.
Large institutional series of LAGB results have been published from centers in Europe and Australia, with good results71,72 for the Lap-Band. Similarly excellent results have been published for the Swedish adjustable band.73 Buchwald and colleagues74 performed a meta-analysis of all bariatric surgical papers published from 1990 to 2003. Overall mortality for LAGB was given as 0.1%. Table 27-6 shows the data from this paper and another meta-analysis75 for weight loss, morbidity, and mortality for LAGB compared with RYGB and the malabsorptive procedures. Table 27-7 also shows data also from Buchwald and colleagues74 regarding the percentage of resolution of four major comorbidities associated with obesity after the most common types of bariatric operations, including LAGB.
Table 27-6Outcomes for bariatric operations ||Download (.pdf) Table 27-6 Outcomes for bariatric operations
| ||LAGB ||RYGB ||BPD/DS |
|% Excess weight loss ||47.5 ||61.6 ||70.1 |
|% Mortality ||0.1 ||0.5 ||1.1 |
|% Morbidity ||10–25 ||13–38 ||27–33 |
|% Nutritional morbidity ||0–10 ||15–25 ||40–77 |
Specific complications that may occur after LAGB include prolapse, slippage, erosion, and port and tubing complications. In addition, just plain failure to lose weight is more commonly seen with this procedure than with other common bariatric procedures.
Prolapse is perhaps the most common emergent complication that requires reoperation after LAGB. The incidence of reoperation is generally around 3%. Postoperative vomiting predisposes to this problem. The lower stomach is pushed upward and trapped within the lumen of the band. Typical patient symptoms include immediate dysphagia, vomiting, and inability to take oral food or liquid. Either anterior or posterior prolapse may occur.76 The initial evaluation for prolapse involves obtaining a plain film radiograph. If the band is in a horizontal position, prolapse must be strongly suspected. This orientation differs from the normal angulation of the band in the 1 to 2 o’clock and 7 to 8 o’clock positions of the two ends of the band on plain radiograph. Initial treatment for a prolapse is to remove all the fluid from the system. This often allows reduction of the prolapse and resolution of symptoms. If symptoms resolve, the necessity of performing an upper gastrointestinal series is lessened. If they do not, an upper gastrointestinal series is indicated, and if prolapse persists, then reoperation laparoscopically to reduce the prolapse and resuture the band in place is indicated.
Slippage has been greatly reduced by the pars flaccida technique, and operative need for repair now occurs in about 3% of cases in most series of short-term follow-up. Longer-term follow-up rates may show higher rates of prolapse. In our experience, a symptom-related need for band deflation, with suspected prolapse, occurs in 10% of patients.
Band erosion is uncommon, reported in 1% to 2% of most series. The patient usually becomes ill but not floridly ill, developing either a port site infection or systemic fever and a low-grade abdominal inflammatory sepsis. Endoscopy can be diagnostic. The presence of otherwise unexplained free air on computed tomography (CT) scan should alert the surgeon to this diagnosis as well. Laparoscopic removal of the band is indicated, with repair of any gastric perforation. Often the perforation is already sealed by an inflammatory process, but if not, appropriate management of a gastric perforation must be followed.76
Port and tubing problems occur in approximately 5% of patients undergoing LAGB. These require revision of the port/tubing system due to perforation, leaking, or kinking of the tubing or turning of the port such that access to the surface of the port for adding fluid is precluded. Usually a procedure under local anesthesia is all that is required to repair or realign the tubing or port.
The incidence of band removal for patient dissatisfaction or lack of weight loss is difficult to assess, since this number is increasing annually at a not small rate. The figure also is likely related to patient follow-up and may be artificially low if the patient seeks a second surgeon to remove a band. The true incidence probably varies widely. Angrisani et al77 reported a 40.9% incidence of band removal after 10-year follow-up.
One of the positive outcomes of LAGB is the safety of the procedure. While complications are not rare, most of them involve non–life-threatening events. Nutritional complications are uncommon and easily treated. Based on worldwide data, the results appear to be optimal in those practices and centers where continued optimal follow-up and encouragement of appropriate behavioral lifestyle changes occur.
The Lap-Band also has its limitations, which may be the cause of its reduced popularity. It is often ineffective in producing adequate weight loss. Restriction of high-caloric liquids, easily digested snacks, and other foods that tend to negate dietary efforts is not adequately achieved with the Lap-Band. Patients must have enough willpower to avoid such foods. If weight loss remains poor, patient frustration and dissatisfaction increase as time passes postoperatively. In centers where suboptimal conditions exist for support and follow-up, the rate of band failure in terms of poor overall weight loss is significant. Reports in the literature tend to only include patients who still have their bands in place and exclude patients who have had bands removed for failure to lose weight. While the latter group of patients probably varies widely from center to center, the trend in many centers to now perform more LRYGB or SG and less LAGB than 5 years ago suggests that LAGB outcomes may rest as much on the postoperative support setting as the operation itself. Centers should reassess their ability to provide optimal follow-up and should do so if possible for optimal long-term results after LAGB.
Laparoscopic Roux-en-Y Gastric Bypass
LRYGB was first described in 1994,25 but by 1998, only a few centers had accumulated any significant experience with the procedure. The University of Pittsburgh was one of those centers, with Schauer and colleagues performing the procedure, and instituted a large number of training courses from 1998 to 2001, which trained many of the bariatric surgeons who adopted the laparoscopic approach. By 2003, over 130,000 gastric bypasses were done in the United States, with more than half of them being done laparoscopically. Currently over 90% of gastric bypass operations nationally are performed laparoscopically.
Figure 27-7 depicts the configuration of the LRYGB. The major feature of the operation is a proximal gastric pouch of small size (often <20 mL) that is totally separated from the distal stomach. A Roux limb of proximal jejunum is brought up and anastomosed to the pouch. The pathway of that limb can be anterior to the colon and stomach, posterior to both, or posterior to the colon and anterior to the stomach. The length of the biliopancreatic limb from the ligament of Treitz to the distal enteroenterostomy is 20 to 50 cm, and the length of the Roux limb is 75 to 150 cm. Longer Roux limb lengths are performed but considered to have more malabsorption than the standard gastric bypass.
Configuration of laparoscopic gastric bypass. (From Schauer PR, et al, eds. Minimally Invasive Bariatric Surgery, 1st ed. New York: Springer; 2007. Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2005-2009. All rights reserved.)
Experience has resolved several controversies about gastric bypass, but others are still debated. It is clear that creating the proximal gastric pouch by totally dividing it from the distal stomach is superior to simply stapling the stomach, since the latter is associated with a high incidence of staple breakdown.78 The size of the proximal gastric pouch must be small to create adequate restriction and should be based on the lesser curvature of the stomach to prevent dilation over time. Length of the Roux limb is associated with higher short-term weight loss for longer length limbs,79 but this difference becomes less on long-term follow-up.80 Some surgeons doing LRYGB will create a longer (150 cm) Roux limb for patients with a BMI over 60 or even 50 kg/m2. Antecolic position of the Roux limb is associated with a lower incidence of internal hernias leading to obstruction in most series with short-term follow-up.81 However, reports with longer follow-up suggest later internal hernia incidence may increase with an antecolic approach.82 Despite the plethora of enthusiasm for reoperative endoscopic narrowing of the gastrojejunostomy opening,83,84,85 good long-term data do not yet exist to confirm that size of the gastrojejunostomy can be related to weight loss. The gastrojejunal anastomosis can be constructed in a variety of ways. Smaller diameter circular staplers are associated with a higher incidence of postoperative stenosis, and linear stapling is associated with a lower incidence of stenosis compared to circular stapling.86,87
The operation generally is performed using five ports plus a liver retractor. Both the surgeon, who stands on the patient’s right, and the first assistant, who stands on the patient’s left, have two ports for instruments. The telescope requires a port, usually in the supraumbilical region. The assistant’s ports are in the left subcostal and flank areas, while the surgeon may have both ports in the right upper quadrant (Cleveland approach) or one on each side of the camera (Virginia approach, Fig. 27-8). Division of the proximal jejunum at 40 to 50 cm distal to the ligament of Treitz is performed with the linear stapler, using the white stapler cartridge. Further division of the mesentery at that location is performed either with the stapler or harmonic scalpel, such that adequate mobilization of the Roux limb is achieved. A Penrose drain or suture is sutured to the proximal Roux limb (Fig. 27-9) for identification and facilitation of advancement to the gastric pouch.
Port scheme for laparoscopic gastric bypass. (From Schauer PR, et al, eds. Minimally Invasive Bariatric Surgery, 1st ed. New York: Springer; 2007. Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2005-2009. All rights reserved.)
Creating Roux limb during laparoscopic gastric bypass.
The length of the Roux limb (usually 100–150 cm) to be created is now measured. A jejunojejunostomy is then created to the proximal end of the biliopancreatic limb at the above-determined location along the Roux limb. A side-to-side stapled anastomosis is performed (Fig. 27-10). Either single- or double-fired staple technique (the latter using a stapler fired in each direction) is used. The stapler defect is optimally closed with sutures but can be closed with a stapler if great care is taken not to narrow the lumen of the alimentary tract at this location. Once the stapler defect is closed, the mesenteric defect is then also closed with running permanent suture.
Enteroenterostomy of laparoscopic Roux-en-Y gastric bypass.
Passage of the Roux limb toward the stomach is now performed. If an antecolic route is to be used, the end of the Roux limb is brought up so as to confirm its ability to reach the stomach. If a retrocolic route is to be used, a defect is made in the transverse colon mesentery just to the left and slightly above the ligament of Treitz. The Penrose drain and the proximal end of the Roux limb are placed into the retrogastric space (Fig. 27-11).
Passage of Roux limb. (From Schauer PR, et al, eds. Minimally Invasive Bariatric Surgery, 1st ed. New York: Springer; 2007. Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2005-2009. All rights reserved.)
The left lobe of the liver is now retracted using any one of several retractor types. The patient is moved to a reverse Trendelenburg position. The harmonic scalpel divides the peritoneum in the area of the angle of His. Then it is used to open an area along the lesser curvature of the stomach approximately 3 cm down from the gastroesophageal junction. Another approach for creating access to the lesser curvature of the stomach is to use a white or gray load (vascular load) of the stapler and divide the lesser curvature vessels up to the surface of the stomach. Then a blue load of the stapler is fired one time transversely from the lesser curvature side partially across the stomach, followed by multiple subsequent firings of the stapler upward in the direction of the angle of His, to completely separate the proximal gastric pouch from the remainder of the stomach (Fig. 27-12). Use of an Ewald tube passed by the anesthesiologist and maneuvered to lie against the lesser curvature of the proximal stomach can help calibrate the pouch size.
Creation of gastric pouch for laparoscopic Roux-en-Y gastric bypass. (From Schauer PR, et al, eds. Minimally Invasive Bariatric Surgery, 1st ed. New York: Springer; 2007. Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2005-2009. All rights reserved.)
Once the pouch is created, the Roux limb is brought up to the proximal gastric pouch. For the linear stapled anastomosis, the proximal end of the Roux limb is aligned with the distal gastric pouch end, and the sides of the organs are sutured together to maintain their side-by-side position. A blue load of the stapler is introduced through a gastrotomy and an enterotomy for the two legs of the stapler, and the anastomosis is created (Fig. 27-13). The stapler defect is closed with sutures and often reinforced with a second layer of sutures. At this point, the gastrojejunostomy is tested for security by using either methylene blue injected under pressure through the Ewald tube or a flexible upper endoscopy intraoperatively to test for air leakage from the anastomosis. The latter technique has been shown to decrease the incidence and seriousness of anastomotic leaks postoperatively.88 The final step of the operation involves suture closure of all mesenteric defects using permanent suture.
Gastrojejunostomy in laparoscopic Roux-en-Y gastric bypass. (From Schauer PR, et al, eds. Minimally Invasive Bariatric Surgery, 1st ed. New York: Springer; 2007. Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2005-2009. All rights reserved.)
Circular anastomosis for the gastrojejunostomy is accomplished through placement of the anvil of the stapler through the anterior wall of the proximal gastric pouch. This is accomplished by pulling the anvil transorally via an endoscopically placed guidewire (Fig. 27-14), making a gastrotomy in the pouch that is later closed, or making a gastrotomy in the lower stomach before completing gastric division to create the pouch, allowing the anvil to be placed into the lumen of the stomach and then be brought through the anterior stomach in an area that is subsequently included in the proximal gastric pouch (Fig. 27-15).
Oral passage of EEA circular stapler to create gastrojejunostomy for laparoscopic Roux-en-Y gastric bypass. (From Schauer PR, et al, eds. Minimally Invasive Bariatric Surgery, 1st ed. New York: Springer; 2007. Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2005-2009. All rights reserved.)
Transgastric passage of circular EEA stapler to create gastrojejuostomy for laparoscopic Roux-en-Y gastric bypass. (Reproduced with permission from Schneider BE, et al. Circular stapled transabdominal technique. In: Schauer PR, et al, eds. Minimally Invasive Bariatric Surgery. 1st ed. New York: Springer; 2007:248. With kind permission of Springer Science + Business Media.)
Hand-sewn gastrojejunostomy is usually created using two layers of absorbable suture to anastomose an approximately 1-cm gastrotomy and enterotomy.
Patient Selection and Preparation
LRYGB is an appropriate operation for consideration for most patients eligible for bariatric surgery. Relative contraindications to LRYGB include previous gastric surgery, previous antireflux surgery, severe iron deficiency anemia, distal gastric or duodenal lesions that require ongoing future surveillance, and Barrett’s esophagus with severe dysplasia. Contraindications to a laparoscopic approach to RYGB should cause the surgeon to choose an open RYGB or other open procedure instead.
Preoperative flexible upper endoscopy is indicated in all patients contemplating undergoing RYGB to rule out lesions of the stomach or duodenum noted earlier.42 Preoperative low-calorie diet for patients with hepatomegaly can decrease liver size and thus improve the chances of completing the operation laparoscopically. We use a mechanical bowel prep to decrease bowel weight and the chance of an inadvertent tear with handling using the laparoscopic graspers.
Postoperative Care and Follow-Up
LRYGB patients are usually hospitalized for 2 to 3 days. Major concerns on the night of surgery include adequate analgesia, adequate fluid resuscitation to provide adequate urine output, and early ambulation. We still routinely employ a postoperative oral contrast study on the first postoperative day. Numerous studies have advocated abandoning this practice due to its lack of accuracy and cost-effectiveness.89,90 The study’s value to us has been to alert us to edema or stenosis of the enteroenterostomy or any other obstructive pattern of the proximal bowel. Obstruction of the enteroenterostomy or beyond can result in distal gastric dilatation over just a period of several hours, which, if untreated, can cause distal gastric staple line rupture with fatal consequences.
Aside from early ambulation, postoperative prophylaxis against venous thromboembolism includes compression shoes and low-molecular-weight subcutaneous heparin. Discharge on a blenderized diet is standard for our practice.
Diet advancement occurs after the first clinic visit, usually approximately 3 weeks after surgery. At that time, an exercise plan is initiated if not already started.
Patients on insulin for type 2 diabetes and on antihypertensive medications should be monitored to determine whether reduction of their medication is indicated. Subsequent follow-up visits are usually scheduled for 3 months, 6 months, and 1 year after surgery, and then annually thereafter. The focus of later postoperative visits is documentation of outcomes and testing for postoperative nutritional deficiencies.
Patients undergoing LRYGB usually lose between 60% and 70% of excess body weight during the first year after surgery. This has held true since the earliest large series of this operation was reported.91 Resolution of comorbidities varies, but is over 90% for GERD and venous stasis ulcers and over 80% for patients with type 2 diabetes of less than 5 years in duration. Hyperlipidemias are almost always improved and resolve totally in about 70% of cases. Hypertension resolves in 50% to 65% of cases (see Table 27-7). Even superobese patients who do not achieve an ultimate BMI of less than 35 kg/m2 can experience significant improvements in comorbidities after LRYGB or open RYGB.92
Table 27-7Effect of bariatric surgery on comorbid medical conditions ||Download (.pdf) Table 27-7 Effect of bariatric surgery on comorbid medical conditions
|CONDITION ||% RESOLVED ||% IMPROVED |
|Diabetes ||76.8 ||85.4 |
|Hypertension ||61.7 ||78.5 |
|Sleep apnea ||83.6 ||85.7 |
|Hyperlipidemia ||70.0 ||96.9 |
Mortality after LRYGB is now consistently less than 0.5% in most large reported series. Recent data from centers applying to be centers of bariatric surgery excellence showed a mortality rate of approximately 0.3% overall. The Bariatric Surgery Center Network (BSCN) of the ACS database showed a mortality of 0.14% at 30 days.93
Overall morbidity after LRYGB has been acceptably low. In the BOLD database of the ASMBS, it was 14.87% for 30,864 gastric bypass procedures.94 In the BSCN database, the 30-day morbidity rate was 5.91% for 14,491 LRYGB procedures.93 LRYGB avoids most wound and incisional hernia problems. Complications that do occur include a 0.3% incidence of anastomotic leak,95 0.33% incidence of venous thromboembolism,96 a 3% to 5% incidence of wound infections or problems,93 a 3% to 15% incidence of marginal ulcers,97 an approximately 7% incidence of bowel obstruction,98 a 4% incidence of postoperative transfusion,99 and a 1% to 19% incidence of anastomotic stenosis,87 based on the type of anastomosis created.
Postoperative nutritional complications after LRYGB include a 66% incidence of iron deficiency, a 5% incidence of iron deficiency anemia, a 50% incidence of vitamin B12 deficiency,100 and an at least 15% incidence of vitamin D deficiency,101 which usually is present preoperatively.
Several complications that are specific to LRYGB must be emphasized. One of the most important is small bowel obstruction. This complication must be treated differently than in the average general surgery patient, whose complication is usually from adhesions and often will resolve with conservative, nonoperative therapy. Patients who have had LRYGB who present with obstructive symptoms generally require surgical therapy on an emergent basis (Table 27-8). This is because the etiology of the bowel obstruction after LRYGB is often an internal hernia from inadequate or nonclosure of the mesenteric defects by the surgeon at the time of operation. Thus, treatment for these patients differs from most patients with small bowel obstruction. One of the most important points of this chapter is to emphasize to general surgeons to be aware of the need to emergently operate on patients after LRYGB who present with small bowel obstruction. Currently, centers that perform small bowel transplantation are seeing patient referral for that procedure after small bowel obstruction after LRYGB, where patients developed infarction of most of the bowel from an internal hernia and have short gut syndrome.102 Other patients, for whom surgery is delayed and the bowel infarcts, do not survive. When the surgeon does encounter bowel obstruction after LRYGB, he or she can expect to see proximally dilated bowel. Cutoff of passage of contrast on CT scan at the enteroenterostomy is particularly suggestive of this diagnosis (Fig. 27-16). The surgical treatment of this particular problem can, if addressed early in the course of the obstruction, be treated laparoscopically. The surgeon must place a trocar for the telescope low enough in the abdomen to adequately survey most of the small intestine. The cecum and terminal ileum are identified, and the bowel is followed retrograde from the terminal ileum to determine the anatomy. Often much of the small bowel is herniated through a mesenteric defect, and only this technique allows the surgeon to reliably identify the bowel and decompress it appropriately. If the bowel is viable, suturing the mesenteric defect is all that is needed for treatment. It should be emphasized that either an antecolic or retrocolic placement of the Roux limb can result in this complication, as internal hernias can arise from either approach.
Table 27-8Complications for which laparoscopic Roux-en-Y gastric bypass patients require urgent surgical intervention ||Download (.pdf) Table 27-8 Complications for which laparoscopic Roux-en-Y gastric bypass patients require urgent surgical intervention
Small bowel obstruction
Early postoperative vomiting with obstructive picture
Early postoperative hematemesis with obstructive picture Intestinal leak Bleeding
Obstruction of contrast at enteroenterostomy with small bowel obstruction from internal hernia after laparoscopic Roux-en-Y gastric bypass.
Marginal ulcers are another complication relatively specific to RYGB, either LRYGB or open RYGB. The patient presents with pain in the epigastric region that is not altered by eating. Diagnosis is by endoscopy. Treatment is medical with proton pump inhibitors, which are effective in 90% of cases. Only those with a gastrogastric fistula to the distal stomach, severe stenosis of the lumen of the gastrojejunostomy, or acute perforation require surgical therapy.
Stenosis of the gastrojejunostomy has been remarkably reduced by the use of a linear stapling technique in our experience.86 Stenosis symptoms usually appear from 6 to 12 weeks postoperatively, but less commonly can occur later. Diagnosis is by upper endoscopy. Treatment is balloon dilatation. Resolution normally occurs with one or two treatments. Less than 10% of patients require reoperation, and those are almost always associated with concurrent marginal ulcers.103
In the immediate postoperative period, anastomotic leak is the single most feared complication after RYGB, either open or laparoscopic. Careful vigilance and a high index of suspicion for this problem are the only appropriate approach, since its presentation may be insidious and the patient’s demise, if untreated, sudden and complete. Tachycardia, tachypnea, fever, and oliguria are the most common symptoms that arouse suspicion for this problem. The treatment is surgical except in rare circumstances where a drain is already in place, no hemodynamic or clinical deterioration is present, and the leak is contained.104 Usual surgical treatment involves repair as feasible, drainage, and creation of a reliable feeding access through a distal Stamm gastrostomy.
In the first few hours or day after surgery, hematemesis indicates bleeding from the gastrojejunostomy unless proven otherwise. The dangers to the patient include aspiration, life-threatening hemorrhage, or more commonly intraluminal hematoma of the Roux limb and enteroenterostomy, which then causes an obstruction of the biliopancreatic limb leading to distal gastric staple line rupture. In fact, any obstructive symptoms in the first few weeks after surgery or any signs of obstruction of the biliopancreatic limb on postoperative swallow studies due to stenosis of the enteroenterostomy require immediate surgical intervention to prevent rupture of the distal gastric staple line. Some reports show that percutaneous decompression of the distal stomach can ameliorate the danger.105 Alternatively, operative therapy to decompress the stomach and treat the obstructive problem is also a reasonable option.
Overall, LRYGB has the significant advantages over open RYGB of avoiding incisional hernias and severe wound infections. Table 27-9 shows the data on these problems, comparing outcomes for laparoscopic versus open procedures at the University of Virginia. Compared with other bariatric surgical procedures, the LRYGB offers a reliable and powerful operation to allow the severely obese patient to lose weight. Although more reliable and greater, this weight loss does come at a slightly higher complication rate compared with LAGB and SG. However, these complication rates, as well as mortality, have been steadily decreasing for LRYGB in the past decade.
Table 27-9Outcomes for laparoscopic versus open Roux-en-Y gastric bypass (University of Virginia 1994–2004) ||Download (.pdf) Table 27-9 Outcomes for laparoscopic versus open Roux-en-Y gastric bypass (University of Virginia 1994–2004)
|CHARACTERISTICS ||LRYGB ||ORYGB ||P VALUE |
|Preoperative body mass index (kg/m2) ||50.9 ± 0.3 ||57.5 ± 0.5 ||<.001 |
|Number of comorbidities ||2.7 ± 0.1 ||3.6 ± 0.1 ||<.001 |
|30-day mortality ||2 (0.3%) ||6 (1.7%) ||<.02 |
|Overall complications ||111 (14.5 %) ||208 (57.3%) ||<.001 |
|Reoperation ||67 (8.8%) ||150 (41.3%) ||<.001 |
|Incisional hernia ||13 (1.7%) ||123 (33.9%) ||<.001 |
|Wound infection ||14 (1.8%) ||27 (7.4%) ||<.001 |
Open Roux-en-Y Gastric Bypass
As described earlier in the chapter, Mason and Itoh26 first described gastric bypass, and Griffin and colleagues27 first described its Roux limb modification. It has been the most time-tested and proven of all bariatric operations. The procedure is now done virtually the same as LRYGB, with the only difference being the access route to perform it. Experienced bariatric surgeons who do not perform laparoscopic surgery still perform this operation with excellent overall outcomes,56 but their numbers are diminishing. RYGB was the most popular operation performed in the United States in the 1990s, but is now far exceeded by LRYGB and LAGB in terms of volume due to the preference of patients to undergo a laparoscopic rather than open procedure. However, for the patient for whom a laparoscopic approach fails, RYGB must be an operation that the bariatric surgeon can perform with skill.
RYGB is performed essentially the same as LRYGB. Some surgeons who use an open approach prefer to perform creation of the gastric pouch as the first part of the procedure, but in essence, the net procedure is the same. Access for open RYGB is usually through an upper midline incision, although a left subcostal incision has been reported to furnish adequate access as well. Closure of the midline wound is performed using a running monofilament suture. Subcutaneous tissues are thoroughly irrigated, and skin is closed with a skin stapler.
Patient Selection and Preparation
Patient selection is essentially the same as for LRYGB, since the operation is the same. Extraordinarily large patients or those with multiple previous abdominal operations, particularly previous gastric surgery, left colectomy, and splenectomy, often require an open incision to perform RYGB. Abdominal wall thickness and liver size are other factors that may require an open incision approach. Patients who have an existing large midline incisional hernia are also candidates for an open approach.
Preparation for open RYGB is identical to LRYGB.
Postoperative Care and Follow-Up
The postoperative care of the patient undergoing open RYGB is very similar to that of the patient undergoing LRYGB. Larger volumes of fluid resuscitation and often more narcotic analgesics are required the day of surgery and often the next as well. Greater attention must be paid to the incision site for potential infection, since an inadequately treated wound infection in these patients can extend easily to the fascial level and cause significant tissue loss before it is fully diagnosed. The perioperative care of open RYGB patients is usually more intense, often because such patients are very large, and concurrently have severe comorbidities, making them higher risk overall for complications of all types. It is interesting, though, that since the era of LRYGB, patients who still undergo open RYGB (usually due to intraoperative conversion) in our practice often are discharged within 1 day of the laparoscopic patients. Our overall length of stay has decreased for RYGB patients based on postoperative pathways geared toward LRYGB.
Postoperative follow-up visits are similar to those of LRYGB patients, with the first visit being timed to appropriately remove skin staples. Other visits, follow-up schedule, and blood testing are identical to LRYGB.
The weight loss statistics and patterns for RYGB are comparable to those of LRYGB, as would be expected. Postoperative deaths are slightly higher for RYGB, but this is almost certainly due to the patient population, which is often among the most severely medically compromised preoperatively. Flum and Dellinger106 showed that for a patient population on Medicare insurance, and hence largely disabled, RYGB had an across-the-board mortality rate of 2.0%. This rate is considerably higher than the 0.3% to 0.4% incidence that was reported for programs applying at that time as bariatric COEs and is in large part due to the patient population. Interestingly, in the report by Flum and Dellinger, surgeons with the most experience had a mortality rate of less than 1.0% for this patient population, suggesting that surgeon experience and patient selection by experienced surgeons influence mortality for RYGB.
One of the most important population studies showing the benefit of bariatric surgery was done in patients undergoing RYGB. Christou and colleagues107 showed a lower incidence of mortality (0.68% vs. 6.17%) in the 5-year follow-up of over 1000 patients undergoing RYGB versus over 5000 severely obese individuals who did not have surgery. This was a reduction of 89% in the death rate.
The incidence of postoperative complications for RYGB is higher than that of LRYGB, due largely to increased morbidity from incisional hernias and other wound-related problems (see Table 27-9). Other than incisional hernias, the long-term results of patients undergoing RYGB are similar to those undergoing LRYGB, including nutritional issues, weight loss, and overall resolution of comorbidities.
Biliopancreatic Diversion and Duodenal Switch
BPD was first described by, and remains championed by, Scopinaro in Italy.32 The operation, which is shown in Fig. 27-17, involves resection of the distal half to two-thirds of the stomach and creation of an alimentary tract of the most distal 200 cm of ileum, which is anastomosed to the stomach. The biliopancreatic limb is anastomosed to the alimentary tract either 75 or 100 cm proximal to the ileocecal valve, depending on the protein content of the patient’s diet. This operation met with limited international popularity, due to the technical difficulty to perform it combined with the significant percentage of nutritional complications that arise postoperatively. However, the procedure did develop a devoted following among a few bariatric surgeons.
Diagram of biliopancreatic diversion. (From Schauer PR, et al, eds. Minimally Invasive Bariatric Surgery, 1st ed. New York: Springer; 2007. Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2005-2009. All rights reserved.)
One complication that plagued the BPD was the development of a high incidence of marginal ulcers postoperatively. Hess and Hess33 and Marceau and colleagues108 separately described the adaptation of the DS operation, originally proposed by DeMeester and colleagues109 for treatment of bile reflux gastritis, to replace the gastric portion of the BPD. This new procedure was originally called BPD with DS. For ease of description, we now simply use the term duodenal switch (DS) to describe this procedure. It is illustrated in Fig. 27-18. Currently BPD and DS represent together less than 3% of bariatric operations performed in the United States, and this rate could be as low as 1% to 2%. The lack of a significant number of surgeons offering the operation, especially via a laparoscopic approach, probably has a great deal to do with that statistic. BPD and DS are, however, recognized as standard bariatric operations and approved for coverage by most insurance companies at this time.
Diagram of duodenal switch. (From Schauer PR, et al, eds. Minimally Invasive Bariatric Surgery, 1st ed. New York: Springer; 2007. Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2005-2009. All rights reserved.)
The technique for BPD will be described for the open approach, but the laparoscopic approach essentially reproduces what is done with the open approach, using different access. Laparoscopic BPD and DS are very technically challenging operations, perhaps another contributing factor to the relatively low numbers of surgeons offering these operations.110
The BPD operation begins with performance of a distal subtotal gastrectomy. A residual 200-mL gastric pouch is created for superobese patients, or a slightly larger pouch is created for patients with a BMI under 50 kg/m2. The terminal ileum is identified and divided 250 cm proximal to the ileocecal valve. The distal end of that divided ileum is then anastomosed to the stomach, creating a 2- to 3-cm stoma. The proximal end of the ileum is then anastomosed side-to-side to the terminal ileum approximately 100 cm proximal to the ileocecal valve. Some surgeons perform the anastomosis only 50 cm proximal to the valve, but in these patients, the likelihood of good protein intake postoperatively should be high. Prophylactic cholecystectomy is performed due to the high incidence of gallstone formation with the malabsorption of bile salts.
The DS procedure differs from the BPD only in the proximal gut portion of the operation. Instead of a distal gastrectomy, resection of all the stomach except for a narrow lesser curvature tube of the stomach is performed. The diameter of this tube is calibrated with a dilator and, if limited to a 32- to 40-French diameter, produces the optimal amount of weight loss while still allowing adequate oral intake. The duodenum is now divided in its first portion, leaving an approximately 2-cm length of duodenum intact beyond the pylorus. This end of the duodenum is then anastomosed to the distal 250 cm of ileum. This anastomosis is often done in an end-to-end fashion with a circular stapler. It is the most difficult portion of the DS procedure, and leak rates are slightly higher than with other anastomoses. The distal bowel configuration and cholecystectomy are similar to BPD.
Patient Selection and Preparation
Patients who undergo either BPD or DS must be prepared for the consequences of a malabsorptive operation. Frequent and large-quantity bowel movement after any large amount of oral intake is common. Patients who have this procedure must be willing to accept frequent, voluminous bowel movements and will also usually modify their eating pattern to restrict intake if access to a bathroom will prove difficult. Patients who undergo either operation must agree to close follow-up preferably by the surgeon. Internists and family physicians may not appreciate the issues related to protein-calorie malabsorption if they occur and treat the patients instead for congestive heart failure. Disastrous results may then occur. Patients must also have the financial means to afford the large number of vitamin and mineral supplements that must be taken to avoid nutritional problems in this patient population.
Given the increased incidence of postoperative nutritional and other complications relative to any of the restrictive operations, BPD and DS usually are recommended only for patients who have superobesity or for whom it is reasonable to believe they will not succeed with the diet and exercise requirements that form the basis for long-term success with restrictive operations. Patients who have failed a restrictive operation and are considering reoperation are candidates for these procedures.
Contraindications to the procedure include geographic distance from the surgeon, lack of financial means to afford supplements, and preexisting calcium, iron, or other nutrient deficiencies.
Postoperative Care and Follow-Up
Patients undergoing BPD or DS must be followed closely and with absolute completeness for nutritional issues long term. Postoperatively, BPD and DS patients face the same potential complications as seen after RYGB. Anastomotic leaks, pulmonary compromise and complications, gastrointestinal bleeding, anastomotic stenosis or obstruction, and infections are all potential concerns during the index hospitalization. The long gastric staple line and the duodenoileostomy of the DS and the duodenal stump and gastroileostomy of the BPD are all areas of anatomic concern postoperatively. Distal anastomotic problems can occur with either procedure as well. Thorough preoperative and postoperative counseling by a nutritionist versed in the operation and potential nutritional deficiencies is essential. Vitamin and mineral supplements must be taken regularly on follow-up, including oral supplements for iron, calcium, and vitamin B12 and a multivitamin. Fat-soluble vitamins must be supplemented in parenteral form. Careful monitoring of protein intake and serum albumin is necessary. More frequent follow-up than with RYGB is needed; checkups at 2-month intervals for the first year and semi-annual or more frequent visits thereafter are appropriate.
Weight loss results with BPD or DS are both excellent and comparable. They also are very durable. One 18-year follow-up study after BPD showed a mean excess weight loss of 70% persisting for that duration of time.111
Although most of the results of BPD or DS are after open operations, one report of laparoscopic DS showed that for 40 patients with an average BMI of 60 kg/m2 the mean hospital stay was 4 days, average operation room time was 3.5 hours, and mean excess weight loss at 9 months was 58%.112
Buchwald and colleagues74 showed that the average weight loss after BPD and DS in the literature was over 70%, with mortality rate of 1.1%, complication rate of 27% to 33%, and nutritional complication rate of 40% to 77% (see Table 27-6).
Complications that occur after the BPD include those seen after RYGB, where intestinal anastomoses and gastric division create potential problems. Scopinaro and colleagues111 reported obstruction in 1.2%, wound infections in a similar rate, and marginal ulcer in 2.8% of patients. However, others found the incidence of marginal ulcer to be higher after BPD, causing the adoption of the DS. Preservation of the pylorus drastically reduces the significant incidence of dumping (poorly quantitated in most series) after BPD. The duodenoileostomy of DS also has a very low rate of stomal ulcer, unlike the gastroileostomy of BPD.
Nutritional complications are by far the most frequent and concerning after both of these operations, particularly on long-term follow up. Scopinaro and colleagues111 reported a protein malnutrition rate of 7%, iron deficiency anemia rate of less than 5%, and bone demineralization at 5 years of 53%. Other problems that may arise include alopecia from inadequate protein absorption, night blindness from a lack of vitamin A, and gallstones if the gallbladder is not removed. However, of all these nutritional complications, protein-calorie malnutrition is the most severe and life-threatening. When it is diagnosed, the treatment is parenteral nutrition. Two episodes of required parenteral nutrition are usually considered adequate indication to lengthen the “common channel” of ileum—the ileum between the ileoileostomy of the biliopancreatic limb to the alimentary tract and the ileocecal valve. The amount that the surgeon should lengthen it is poorly documented, but most surgeons will favor making it long enough to be certain to avoid recurrence of the problem, such as doubling the length of the common channel, even if it decreases weight loss somewhat.
It cannot be emphasized enough that patients who undergo either BPD or DS should be impressed with the fact that lifetime nutritional supplements and lifetime follow-up are essential to preserve good health after these operations.
Laparoscopic Sleeve Gastrectomy
Laparoscopic sleeve gastrectomy has taken the bariatric surgical scene by storm over the past 5 to 10 years. It is rapidly increasing in popularity, and by the time this book is published, it may be, in some countries and areas, the most popular bariatric and metabolic operation performed. Its rapid rise in popularity coupled with good initial results suggest that it will be a major component of patient care for the treatment of morbid obesity and its comorbid medical problems for years to come in the future.
Since sleeve gastrectomy is performed almost exclusively using a laparoscopic approach, the remainder of this text will use the simple term sleeve gastrectomy (SG) to describe the procedure, with the understanding that it is routinely performed using a laparoscopic approach. SG had its origins in the early days of laparoscopic bariatric surgery. The procedure represents the gastric portion of the DS procedure.33 Ren and colleagues112 reported an initial experience of performing DS using a laparoscopic approach that had relatively higher mortality than seen with gastric bypass or other treatment options being performed laparoscopically. This was in part due to the fact that patients selected to receive DS often were significantly larger and had more numerous and more severe comorbid medical problems. Gagner began to perform the gastric resection portion of the DS operation as a first-stage procedure. After patients had lost weight, the malabsorptive component of the procedure was then performed. However, many of the patients had such good results after the first stage of the procedure that they refused to proceed to the second portion.113 Thus, the concept of performing SG as a primary procedure was born.
Until 2009, SG was considered an “experimental” procedure by insurance carriers. That year, the ASMBS reviewed the data on the procedure and published a statement in January of 2010 recognizing the procedure had adequate data and results to support its use as a primary bariatric operation for carefully selected patients.114 Shortly thereafter, SG received a designated Common Procedural Terminology (CPT) code. Since that time, insurance carriers have recognized the procedure as being appropriate for treating severe obesity and its comorbid problems. The final carrier, Medicare and Medicaid in the United States, issued a statement in April 2012 that left the determination of coverage of this procedure to the regional insurance carriers administering Medicare. This happened only after a hearing to determine coverage in which a great deal of data was presented in favor of the procedure. The initial conclusion of that panel was that SG should be reimbursed if performed in the setting of a prospective randomized trial. However, subsequent public opinion and data caused CMS to revise its decision to allow regional carriers to determine coverage.
SG has the advantage of being a technically easier operation to perform than gastric bypass, while achieving better efficacy in treating comorbid medical problems and producing superior weight loss than LAGB. Once the results of the procedure began to be published, understood, and accepted, its popularity rose dramatically. In the United States, the incidence of performing SG has risen rapidly since 2008, as shown in Fig. 27-19. The incidence of SG is increasing at a rate that suggests that within the next 2 years it may pass LRYGB as the most popular bariatric operation performed in the United States.
National U.S. Bariatric Volume Percentage by Procedure Type. (Reproduced with permission from Buchwald H, Oien DM: Metabolic/bariatric surgery worldwide 2011. Obes Surg. 2013;23:427. With kind permission of Springer Science+Business Media.)
Throughout the rest of the world, the popularity of SG has also risen dramatically in the past 5 to 8 years. In Asia, where there is a high incidence of gastric cancer in countries such as Japan, SG makes more sense anatomically as an appropriate treatment for severe obesity. In India, where the high incidence of diabetes in the obese population makes metabolic and bariatric surgery a desirable option, SG has gained popularity once its effectiveness in treating diabetes was shown. Figure 27-20 shows the trend in performance of several bariatric operations in Asia from 2003 to 2011, during which the totals of those procedures from surgeons surveyed increased over 500%.37 This rise in bariatric and metabolic surgery was comparable to the same increase in percentage of cases performed seen in the United States from 1998 to 2003. In Europe, the past few years have seen a clear trend away from performing LAGB and a higher incidence of performing both SG and LRYGB.37
Asia/Pacific Bariatric Volume Percentage by Procedure Type. (Reproduced with permission from Buchwald H, Oien DM: Metabolic/bariatric surgery worldwide 2011. Obes Surg. 2013;23:427. With kind permission of Springer Science+Business Media.)
Patient selection for SG is comparable to that for other bariatric and metabolic operations with a few notable exceptions. SG was originally introduced as the first of a two-stage operative treatment for patients with super obesity (BMI >60 kg/m2).115 It remains an effective first- or second-stage treatment for such patients. Whether a second stage is indicated depends on the effectiveness of the SG. SG has been shown to be safe and effective in adolescent obese patients.116 It has also been shown to be an acceptable procedure for the elderly obese patient.117 SG effectively treats most of the comorbid medical problems associated with obesity. The one exception is GERD. Patients with GERD experience less resolution of their symptoms after SG than do patients with LAGB, even when the LABG patients lost less weight overall.93 Patients who have longstanding severe GERD may not be good candidates for SG. Barrett’s esophagus is considered a relative contraindication for performing SG, since the potential for future esophagectomy and the need for an available intact stomach for reconstruction outweigh the potential advantages of the procedure.
The patient is positioned supine, with foot support to allow reverse Trendelenburg positioning. The surgeon stands to the patient’s right along with the camera driver, while the assistant stands to the patient’s left. Port placement may vary from institution to institution, but our recommended port placement is shown in Fig. 27-21. The 15-mm port, helpful for removal of the stomach, is located in either the camera (just to the patient’s left of the umbilicus) or surgeon’s right hand (right upper quadrant near the midline) location. The other of these ports is a 12-mm port. The assistant has two 5-mm ports available in the left upper quadrant laterally, and the surgeon’s left hand port is a 5-mm port more lateral and superior in the right upper quadrant. A liver retractor is placed in the epigastric region. This can be a Nathanson or T-Boone retractor.
Port scheme for Laparoscopic sleeve gastrectomy.
The operation begins by devascularizing the greater curvature of the stomach, beginning 3 to 5 cm proximal to the pylorus. The harmonic scalpel works nicely to perform this tissue division. The division of all vessels adjacent to the greater curvature is continued up to the left crus of the diaphragm. A complete mobilization of the fundus in this area and division of posterior fibrous attachments to the antrum and body of the stomach are then performed such that the stomach is attached solely by the lesser curvature blood supply and the pyloric and esophageal regions. Stapled division of the stomach now follows. The first firing of the stapler occurs from the point of devascularization of the greater curvature at an angle pointing toward a point about 2 cm lateral to the incisura. The antrum of the stomach is at its thickest here, and so it is important to be certain the stapler load used is sufficiently large enough to allow good approximation and closure of the divided stomach. We have favored use of the black load (2.5-mm staple height) in all males with a BMI over 45 kg/m2, females with a BMI over 55 kg/m2, or anyone whose stomach looks particularly thick. A green load (staple height of 2 mm when closed) is used for less thick stomachs or smaller individuals. We continue the use of this color load for the first two firings, which takes the gastric division to past the incisura. After the first staple firing, some surgeons will engage the anesthesiologist to pass a 32- to 36-French bougie and position it along the lesser curvature of the stomach. This bougie then serves as a guide for further gastric division. Alternatively, some surgeons will insert the endoscope instead of the bougie as a guide for gastric division. It can also be used to test for air leaks, bleeding, or obstruction as it is withdrawn after gastric division. Dividing the stomach adjacent to the bougie or endoscope will produce the desired diameter of the gastric sleeve. It is most important not to narrow the stomach lumen at the incisura. During the second and third firing of the stapler to divide the stomach, it is critical to confirm by visualization of both the anterior and posterior surfaces of the stomach that the incisura area is not narrowed. By the third firing of the stapler, usually the angle of the gastric division is now pointed directly toward the angle of His, parallel to the bougie (Fig. 27-22). At this point, changing staple loads to lower staple height is advisable. We usually switch to gold then blue staple loads as we progress proximally in dividing the stomach. It is essential that with each firing of the stapler, adequate time (10–20 seconds) is allowed for tissue compression to allow optimal staple closure and security of the divided tissue.
Performing sleeve gastrectomy. (From Schauer PR, et al, eds. Minimally Invasive Bariatric Surgery, 1st ed. New York: Springer; 2007. Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2005-2009. All rights reserved.)
Once the stomach is completely divided up to the angle of His, the staple line is inspected for hemostasis and integrity. Some surgeons will reinforce the staple line with a buttress material, while others will invaginate the staple line with a running serosa to serosa suture. Some surgeons will exchange the bougie at this point for a 32-French Ewald tube and perform a methylene blue leak test. Alternatively, if an endoscope is used, it is withdrawn with insufflation, and the staple line is inspected for air leaks while submerged in saline. The specimen is removed through the 15-mm trocar site, usually with only slight enlargement of the site. Figure 27-23 shows the completed operation.
Completed sleeve gastrectomy. (From Schauer PR, et al, eds. Minimally Invasive Bariatric Surgery, 1st ed. New York: Springer; 2007. Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2005-2009. All rights reserved.)
Controversy still exists as to the optimal size of the bougie used during the procedure. One summary of the literature shows that the stenosis rate is lower if a 40-French bougie is used, and the leak rate may also be lower without compromising weight loss.118 However, individual institutional experiences with smaller-sized bougies have shown the potential for exceptionally good weight loss and no increased incidence of stenosis.119 Another controversial area is that of staple line reinforcement with staple buttressing material. Some surgeons advocate routine staple line reinforcement, whereas others advocate none. Still others advocate oversewing of the staple line in areas of bleeding or in selected cases that show a predilection for bleeding intraoperatively. Other experts advocate routine oversewing of the entire staple line.120 At this time, there is no preponderance of data to support one approach as being superior to others.
Postoperative Care and Follow-Up
SG usually is performed with an overnight stay of 2 nights after surgery. Longer hospitalizations are indicated for patients with more severe medical problems. Absence of signs of bleeding and a documented intact staple line with good gastric emptying are required prior to discharge. Routine Gastrografin swallow on the first day after surgery is used by many surgeons, but its efficacy and cost-effectiveness have yet to be clearly documented. Follow-up is similar to that after LRYGB. Few nutritional complications occur unless the patient has difficulty taking in enough nutrients or protein or vitamins due to edema or tightness of the sleeve lumen. Most surgeons advocate routine vitamin B12. Iron supplementation may be required as well since iron in the diet is usually drastically restricted by elimination of many foods rich in iron. It is unclear whether the same need for vitamin D supplementation seen after LRYGB is also needed after SG, since there is a high incidence of low 25-hydroxyvitamin D levels preoperatively in patients undergoing SG.121 Routine multivitamins are usually prescribed to avert any potential other shortages from dietary vagaries.
The other aspect of weight loss that must be considered in the nutritional aspects of postoperative care and follow-up after SG is that patients are at risk of losing significant lean body mass while they are also losing weight. Damms-Machado and colleagues121 showed that SG patients’ lean body mass decreased from 74.8 kg to 62.3 kg at 1 year after SG. This emphasizes the need for high protein content in the postoperative diet of SG patients to maintain lean body mass.
Outcomes and Complications
Reports in the literature of the success and excellent weight loss after SG have been accumulating since 2006.122,123 The first very large series from a single institution reported 750 patients undergoing SG as a primary weight loss procedure. Five-year follow-up of some patients was available, and a hospital stay averaging 1.7 days, a major complication rate under 5%, an operative time under 80 minutes, and no conversions or mortality were reported.124
Brethauer and colleagues125 published an excellent review of the early data on SG through 2009. For the collected number of patients treated with SG (2750 patients), the excess weight loss rate was 55.4%. Studies with 5-year follow-up for SG are not yet common. One highly successful series was recently reported by Rawlins and colleagues119 for 49 patients followed for 5 years after SG with an average weight loss of 86% of excess weight and a decrease in average BMI from 65 to 35 kg/m2. One of the longest follow-up studies for SG by Eid and colleagues126 demonstrated an average excess weight loss of 48% and BMI decrease from 66 to 46 kg/m2 in 74 superobese patients with 6- to 8-year follow-up.
Prospective randomized trials comparing SG with other procedures have shown that SG is superior to LAGB for excess weight loss at 3 years (66% vs. 48%).127 One study reported that SG achieved a superior excess weight loss compared with LRYGB (69.7% vs. 60.5%) at 1 year after surgery. This study also found greater appetite suppression and a lower serum ghrelin level for SG.128
SG has been included in the results of large databases showing outcomes after bariatric surgery. Data from the ACS BSCN showed that SG was positioned between LAGB and LRYGB for efficacy of weight loss and resolution of comorbid medical problems and for morbidity and mortality.93
As noted earlier, controversy exists as to whether the use of buttress materials with the stapling of the stomach improves outcomes. The overall bleeding rate for the staple line after SG is generally cited as about 2% in collected series.125 There have been no studies that have shown a definitive decrease in this bleeding rate with the use of buttress materials; however, a panel of experts has voiced support for a decreased incidence of bleeding from the staple line if buttress material is used.120
Measures to prevent staple line leakage are similarly controversial with respect to buttress materials and other measures. It is certain that appropriate stapling technique in dividing the stomach is important. Using an adequately high staple height for the tissue to be divided and allowing an adequate amount of time for tissue decompression within the stapler jaws before firing are essential to minimize the likelihood of a staple line leak. Failure to perform gastric division appropriately in this fashion will lead to an early staple line leak after surgery. Whether buttress materials do decrease the leak rate with SG is very controversial. One meta-analysis did show that there is evidence to suggest buttress materials may decrease this rate.129 Other prospective randomized studies have failed to show a benefit of buttress materials.130 To date, the literature has not clearly shown a benefit for using buttress materials in terms of leak prevention.
Perhaps the major factor that is different in SG than other gastric stapling procedures is that SG creates a high-pressure gastric tube. This increased intraluminal pressure places the staple line at risk for leakage. If there is a relative obstruction or stenosis of the sleeve, which most often may occur at the incisura due to narrowing there during formation of the sleeve, pressure above the level of the obstruction will be even more elevated and create an increased risk for staple line leak. Leaks of the proximal staple line are the most frequent type seen after SG and often are felt to be related to increased intraluminal pressure distally. They may also be related to stapling too close to the angle of His, with resultant instability of the tissue directly adjacent to the esophagus in this area. It is important not to staple too close to the angle of His during the final stapling division portion of the stomach so as to not further weaken the staple line in this area. Proximal staple line leaks may also present as late leaks. Late leaks are generally felt to be those that occur 6 weeks or longer after surgery. Late leaks are rare in other bariatric procedures, but are seen with SG. The increased pressure of the system may be a reason SG is associated with late leaks. Confirmation and treatment of stenosis symptoms early after SG may prevent such leaks.
Distal staple line leaks are different than proximal staple line leaks, and are usually associated with earlier presentation and related to mechanical failure of the staple line to securely approximate the thicker distal gastric tissue. These leaks are more amenable to successful repair with a reoperation, whereas proximal leaks may not improve with oversewing at a reoperation unless the mechanics of the relative distal obstruction and high intraluminal pressure of the sleeve are also treated. Endoscopic intervention to dilate stenotic areas as well may be beneficial in the setting of a stenosis with or without a proximal leak. Care must be taken by the endoscopist to not excessively dilate the tract beyond the original size of the bougie used. Another factor that may influence stenosis at the incisura is that there may be a relative twisting of the stomach at this location, with the antrum being partially twisted away from the upper portion of the sleeve. Endoscopic treatment can help straighten and markedly alleviate the obstruction in such cases. Thus relatively early endoscopic intervention is appropriate in the patient with a stenosis at the incisura. One study has shown that endoscopic dilation is usually successful in treating stenosis after SG, with a mean of 1.6 dilatations being done an average of 48 days postoperatively.131
The patient with the proximal gastric staple line leak due to mechanical factors may experience a persistence of the leak for months. Such cases are now only recently being published and discussed in the literature. It is unclear how long one should optimally treat such a leak conservatively with the likelihood it will close. Reports of such leaks persisting for multiple months postoperatively exist. Our own experience has been that eventual closure of such a leak is possible even 4 months postoperatively. However, longer duration leaks are less likely to close. Some experts have now advocated conversion of the patient with a longstanding leak after SG to a RYGB to provide a low-pressure anastomosis above the site of the stenosis. Similarly, persistent stenosis of the sleeve despite conservative therapy and endoscopic dilatation also is an indication for conversion to LRYGB.
Physiology of Weight Loss
SG is a fairly simple technical operation, amenable to performance by many surgeons. The results of the operation for weight loss have been excellent and dramatic. However, the mechanisms of the resolution of comorbidities, such as diabetes, are still not totally clear. While weight loss alone may provide the majority of the physiologic changes that improve comorbid problems such as diabetes and hypertension, it is also possible that other factors may be involved. Certainly SG, through gastric resection, eliminates much of the ghrelin-producing portion of the stomach. The resolution of type 2 diabetes after SG is remarkable, although not as good as that seen after RYGB. The reasons for this are as yet unclear, since lap RYGB has been shown to have independent factors influencing glucose metabolism separate from weight loss alone. The hormonal and peptidergic changes produced by SG in terms of appetite suppression, glucose metabolism, and other metabolic pathways have yet to be clarified. A recent hypothesis summarized by Ed Mason132 is that the rapid emptying of the stomach after SG creates a similar exaggerated release of GLP-1 as seen after LRYGB, and this results in the improved carbohydrate metabolism and improvement of type 2 diabetes seen after SG, as after LRYGB.133
There is some concern among the bariatric surgical community that SG, because it is technically not that difficult, could become a procedure performed by surgeons without a full support system and follow-up mechanism for bariatric patients. The bariatric surgery community feels strongly that this procedure should remain a procedure done within the confines of the COE framework. This will ensure optimal patient outcomes.