Surg Today DOI 10.1007/s00595-014-1097-8
ORIGINAL ARTICLE
Laparoscopic resectional gastric bypass: initial experience in morbidly obese Korean patients Ji Yeon Park · Yong Jin Kim
Received: 7 August 2014 / Accepted: 27 October 2014 © Springer Japan 2014
Abstract Purpose Roux-en-Y gastric bypass (RYGB) is thought to be the gold standard treatment for morbid obesity. However, concerns have been raised by investigators in areas where gastric cancer is prevalent regarding the inaccessibility of the excluded stomach to regular surveillance. This study aimed to evaluate the technical feasibility and shortterm surgical outcomes of resectional RYGB. Methods Sixteen consecutive patients who underwent laparoscopic gastric bypass with distal gastric resection for the primary purpose of weight loss between January 2011 and December 2013 were retrospectively reviewed. The perioperative outcomes and weight loss results of these patients were analyzed. Results All procedures were successfully performed laparoscopically. The mean length of the operation and the mean hospital stay were 170 min (range 110–225) and 4 days (range 2–7), respectively. The prevalence of early postoperative complications reached 18.7 % after resectional RYGB, but a severe complication requiring reoperation occurred in only one patient (6.3 %). The percent of excess weight loss was 78.9 % over a mean follow-up period of 14 months. Obesity-related comorbidities including diabetes, hypertension and dyslipidemia resolved or improved after surgery in most patients. Conclusion Resectional RYGB is technically feasible and can be a viable option in countries with a high risk of
J. Y. Park · Y. J. Kim (*) Department of Surgery, Soonchunhyang University Seoul Hospital, 59, Daesagwan‑ro, Yongsan‑gu, 140‑743 Seoul, Republic of Korea e-mail: [email protected] J. Y. Park e-mail: [email protected]
gastric cancer, where surgeons are already well trained in laparoscopic gastrectomy. Keywords Morbid obesity · Bariatric surgery · Gastric bypass · Gastrectomy
Introduction Morbid obesity is a rapidly growing problem worldwide and is accompanied by various kinds of obesity-related comorbidities. Bariatric surgery has proven to be the most effective therapeutic option to achieve sustained weight loss in morbidly obese patients, and consequently, improves obesity-related comorbidities such as type 2 diabetes and cardiovascular diseases. This positive effect is reflected in significant cost savings through a reduction in the utilization of health services soon after bariatric surgery [1]. Roux-en-Y gastric bypass (RYGB) has been the most commonly performed bariatric procedure throughout the world, and is considered the gold standard among the various surgical options available for the management of morbid obesity [2]. Since it was first developed by Mason and Ito in the 1960s [3], this procedure has undergone several modifications with the aims of improving its weight loss efficacy and reducing surgical complications [4, 5]. The outcomes of RYGB have been extensively studied and discussed by many researchers, and most of the literature suggest that RYGB is a promising method of handling morbid obesity and its associated comorbidities [6–8]. Conventional RYGB is characterized by the following: the creation of a small gastric pouch with a small gastrojejunal anastomosis for intake restriction, a Rouxen-Y reconstruction with a long alimentary limb (the usual length ranges from 75 to 150 cm) to force food
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to bypass the absorption area of the proximal small bowel, leaving the excluded stomach in situ. The primary rationale for preserving the bypassed stomach has been to maintain the reversibility to the original anatomy. Given the concerns of bariatric surgeons who want to avoid hazardous consequences to the patient as a result of the operation, it is reasonable to minimize the manipulation of the intra-abdominal organs and to leave the excluded stomach untouched. However, concerns have been raised about this distal remnant stomach, which becomes a complete “blind loop”. Particularly in regions where gastric malignancy prevails, there are serious concerns about the possibility of cancer development in the excluded stomach and about its detection after RYGB. Therefore, some investigators from areas where gastric cancer is prevalent proposed an RYGB with resection of the remnant stomach as a solution to the issue [9, 10]. We herein report our initial experiences with laparoscopic resectional RYGB in morbidly obese patients in Korea. The current study aimed to evaluate the technical feasibility and surgical outcomes of resectional RYGB.
Patients and methods All consecutive patients who underwent laparoscopic gastric bypass with distal gastric resection at Soonchunhyang University Seoul Hospital in Korea between January 2011 and December 2013 were included, and their medical records were retrospectively reviewed. Baseline, perioperative and follow-up data from a prospectively established database were thoroughly reviewed and summarized. Patients who received resectional gastric bypasses for revisional purposes were excluded from the study. Approval for this review of hospital records was obtained from the institutional review board (SCHUH 2014-09-013); the need for patient informed consent was waived. The institutional guidelines for bariatric surgery were as follows: obese patients with a BMI greater than 30 kg/ m2 with obesity-related comorbidities (e.g., diabetes, sleep apnea, hypertension or obesity related arthropathy) or with a BMI of 35 kg/m2 or greater. Resectional RYGB, in which the excluded stomach was completely removed, was usually performed in patients who desired to undergo a resection due to the presence of a precancerous lesion in the stomach or who seriously feared the potential occurrence of cancer in the excluded stomach due to a family history of gastric cancer. Patients made the decision to undergo a resectional RYGB after being fully informed about possible complications associated with the additional resection of the stomach.
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Surg Today
Surgical procedures All procedures were performed laparoscopically by a single surgeon with sufficient experience in upper gastrointestinal and bariatric surgeries. Laparoscopic resectional RYGB was performed via three 5-mm and two 12-mm ports. After the left lateral lobe of the liver was lifted with a liver retractor to expose the angle of His, the omentum of the stomach was divided along the whole length of the greater curvature using a Harmonic scalpel® (Ethicon Endo-Surgery, Cincinnati, OH, USA). Short gastric vessels around the fundus were similarly divided when performing sleeve gastrectomy. Adhesions between the anterior face of the pancreatic head and the posterior wall of the duodenal bulb were carefully dissected for full exposure of the pyloric ring. The gastrohepatic ligament was opened along the avascular plane, and the right gastric artery was identified and divided. The duodenum was transected with an endo GIA™ (Covidien, Mansfield, MA, USA). After checking the left gastric artery for anatomical variations, the main descending branch of the left gastric artery was divided with a LigaSure™ device (Covidien, Mansfield, MA, USA). Then, a small gastric pouch approximately 30 mL in volume was created along the lesser curvature using laparoscopic linear staplers, while carefully preserving the blood supply from the ascending branch of the left gastric artery to avoid pouch ischemia (Fig. 1). A gastrojejunal anastomosis was constructed using a linear stapler, and the entry hole of the stapler blades was hand-sewn closed. The Roux limb was positioned in an antecolic fashion. Afterward, a latero-lateral jejunojejunal anastomosis was established, with a 40-cm biliopancreatic limb and a 70-cm alimentary limb. All mesenteric defects were closed with non-absorbable suture materials. The stomach specimen was retrieved via an umbilical port site after extending the original incision. Postoperative management and data collection A prospectively established database and the medical records were retrospectively reviewed to analyze the preoperative demographics and surgical outcomes. The assessment of intraoperative parameters included the length of the operation, amount of blood lost during the operation and the presence of intraoperative complications. The length of the operation was defined as the time from skin incision to wound closure. The postoperative hospital stay and complications were also assessed. Complications were additionally graded according to the Accordion Severity Grading System [11]. The absence of postoperative leakage or passage disturbance was confirmed by a contrast upper gastrointestinal study. Patients then initiated oral intake on the morning of
Surg Today
Fig. 1 The steps performed during the resectional RYGB. a, b Division of the omentum along the whole length of the greater curvature, c ligation of the right gastric artery, d transection at the first portion
of the duodenum, e verification of the anatomical orientation of the left gastric artery, f, g division of the main descending branch of the left gastric artery, h creation of a small gastric pouch
the first postoperative day. Patients were discharged once they achieved adequate oral intake, their pain was under control and they were walking without difficulty. The
postoperative nutritional regimen consisted of a liquid or soft diet for the first three weeks, with a gradual expansion of the food texture thereafter. Patients returned to the
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outpatient clinic two weeks after surgery and every three months thereafter for the first postoperative year to monitor weight loss, appetite, dysphagia or food intolerance, eating behavior, the comorbidity status and the presence of any complications. After the first year, the follow-up frequency was decreased to every 12 months. Patients who could not visit the outpatient clinic were monitored by telephone interview. The degree of weight loss was assessed based on the percent of excess weight loss (%EWL) and the percent of excess BMI loss (%EBMIL) [12]. The ideal weight calculated by the formula corresponding to the mid-point of the medium frame of the Metropolitan Tables was used to assess the %EWL [13]. The %EBMIL was calculated using a BMI of 23 kg/m2 as the upper limit of normal according to the World Health Organization (WHO) recommended definition of obesity for Asians [14].
Surg Today Table 1 The patient demographics and comorbidities (n = 16) Age (years) Sex Male Female Body weight (kg) BMI (kg/m2) Comorbidities Diabetes Hypertension Dyslipidemiaa Obstructive sleep apnea Obesity-related arthropathy PCOS Presence of H. pylorib
41 (25–58) 0 16 95.0 (66.0–137.0) 36.9 (26.4–51.6) 5 3 10 0 1 3 7 (43.8)
Figures are presented as the medians (range) or the number of patients BMI body mass index, PCOS polycystic ovarian syndrome
Results A total of 16 patients underwent resectional RYGB during the study period. The detailed demographic data of these patients are shown in Table 1. All patients were female and their mean BMI was 36.9 kg/m2 (range 26.4–51.6). Of the 16 patients, 13 (81.3 %) had at least one obesity-related comorbidity at the preoperative evaluation. The most frequently encountered obesity-related comorbidity was dyslipidemia (10/16, 62.5 %). Seven patients (43.8 %) were proven to be positive for Helicobacter pylori infection before the surgery. The perioperative surgical outcomes of these patients are shown in Table 2. The mean length of the operation time and hospital stay were 170 min (range 110–225) and 4 days (range 2–7), respectively. There was no laparotomic conversion and all procedures were successfully performed laparoscopically. Early postoperative complications developed in three patients (18.7 %). Detailed information on the postoperative complications following resectional RYGB is shown in Table 3. All early complications, which occurred within one month after surgery, were related to immediate postoperative bleeding. Among the two patients who presented with intra-abdominal bleeding, one showed unstable vital signs with evident ongoing bleeding through a closed drain immediately after the surgery and required urgent reoperation for hemostasis. The other showed sanguineous drainage via a closed drain, as well as a hemoglobin drop of 2.1 g/dL over 24 h on the first postoperative day. The patient was closely observed without any intervention or transfusion and was discharged on the seventh postoperative day when further bleeding was no longer evident. One patient manifested melena on the second postoperative day with a hemoglobin drop of
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a Definition of dyslipidemia: total cholesterol ≥240 mg/dL, LDL-C ≥160 mg/dL or HDL-C
ORIGINAL ARTICLE
Laparoscopic resectional gastric bypass: initial experience in morbidly obese Korean patients Ji Yeon Park · Yong Jin Kim
Received: 7 August 2014 / Accepted: 27 October 2014 © Springer Japan 2014
Abstract Purpose Roux-en-Y gastric bypass (RYGB) is thought to be the gold standard treatment for morbid obesity. However, concerns have been raised by investigators in areas where gastric cancer is prevalent regarding the inaccessibility of the excluded stomach to regular surveillance. This study aimed to evaluate the technical feasibility and shortterm surgical outcomes of resectional RYGB. Methods Sixteen consecutive patients who underwent laparoscopic gastric bypass with distal gastric resection for the primary purpose of weight loss between January 2011 and December 2013 were retrospectively reviewed. The perioperative outcomes and weight loss results of these patients were analyzed. Results All procedures were successfully performed laparoscopically. The mean length of the operation and the mean hospital stay were 170 min (range 110–225) and 4 days (range 2–7), respectively. The prevalence of early postoperative complications reached 18.7 % after resectional RYGB, but a severe complication requiring reoperation occurred in only one patient (6.3 %). The percent of excess weight loss was 78.9 % over a mean follow-up period of 14 months. Obesity-related comorbidities including diabetes, hypertension and dyslipidemia resolved or improved after surgery in most patients. Conclusion Resectional RYGB is technically feasible and can be a viable option in countries with a high risk of
J. Y. Park · Y. J. Kim (*) Department of Surgery, Soonchunhyang University Seoul Hospital, 59, Daesagwan‑ro, Yongsan‑gu, 140‑743 Seoul, Republic of Korea e-mail: [email protected] J. Y. Park e-mail: [email protected]
gastric cancer, where surgeons are already well trained in laparoscopic gastrectomy. Keywords Morbid obesity · Bariatric surgery · Gastric bypass · Gastrectomy
Introduction Morbid obesity is a rapidly growing problem worldwide and is accompanied by various kinds of obesity-related comorbidities. Bariatric surgery has proven to be the most effective therapeutic option to achieve sustained weight loss in morbidly obese patients, and consequently, improves obesity-related comorbidities such as type 2 diabetes and cardiovascular diseases. This positive effect is reflected in significant cost savings through a reduction in the utilization of health services soon after bariatric surgery [1]. Roux-en-Y gastric bypass (RYGB) has been the most commonly performed bariatric procedure throughout the world, and is considered the gold standard among the various surgical options available for the management of morbid obesity [2]. Since it was first developed by Mason and Ito in the 1960s [3], this procedure has undergone several modifications with the aims of improving its weight loss efficacy and reducing surgical complications [4, 5]. The outcomes of RYGB have been extensively studied and discussed by many researchers, and most of the literature suggest that RYGB is a promising method of handling morbid obesity and its associated comorbidities [6–8]. Conventional RYGB is characterized by the following: the creation of a small gastric pouch with a small gastrojejunal anastomosis for intake restriction, a Rouxen-Y reconstruction with a long alimentary limb (the usual length ranges from 75 to 150 cm) to force food
13
to bypass the absorption area of the proximal small bowel, leaving the excluded stomach in situ. The primary rationale for preserving the bypassed stomach has been to maintain the reversibility to the original anatomy. Given the concerns of bariatric surgeons who want to avoid hazardous consequences to the patient as a result of the operation, it is reasonable to minimize the manipulation of the intra-abdominal organs and to leave the excluded stomach untouched. However, concerns have been raised about this distal remnant stomach, which becomes a complete “blind loop”. Particularly in regions where gastric malignancy prevails, there are serious concerns about the possibility of cancer development in the excluded stomach and about its detection after RYGB. Therefore, some investigators from areas where gastric cancer is prevalent proposed an RYGB with resection of the remnant stomach as a solution to the issue [9, 10]. We herein report our initial experiences with laparoscopic resectional RYGB in morbidly obese patients in Korea. The current study aimed to evaluate the technical feasibility and surgical outcomes of resectional RYGB.
Patients and methods All consecutive patients who underwent laparoscopic gastric bypass with distal gastric resection at Soonchunhyang University Seoul Hospital in Korea between January 2011 and December 2013 were included, and their medical records were retrospectively reviewed. Baseline, perioperative and follow-up data from a prospectively established database were thoroughly reviewed and summarized. Patients who received resectional gastric bypasses for revisional purposes were excluded from the study. Approval for this review of hospital records was obtained from the institutional review board (SCHUH 2014-09-013); the need for patient informed consent was waived. The institutional guidelines for bariatric surgery were as follows: obese patients with a BMI greater than 30 kg/ m2 with obesity-related comorbidities (e.g., diabetes, sleep apnea, hypertension or obesity related arthropathy) or with a BMI of 35 kg/m2 or greater. Resectional RYGB, in which the excluded stomach was completely removed, was usually performed in patients who desired to undergo a resection due to the presence of a precancerous lesion in the stomach or who seriously feared the potential occurrence of cancer in the excluded stomach due to a family history of gastric cancer. Patients made the decision to undergo a resectional RYGB after being fully informed about possible complications associated with the additional resection of the stomach.
13
Surg Today
Surgical procedures All procedures were performed laparoscopically by a single surgeon with sufficient experience in upper gastrointestinal and bariatric surgeries. Laparoscopic resectional RYGB was performed via three 5-mm and two 12-mm ports. After the left lateral lobe of the liver was lifted with a liver retractor to expose the angle of His, the omentum of the stomach was divided along the whole length of the greater curvature using a Harmonic scalpel® (Ethicon Endo-Surgery, Cincinnati, OH, USA). Short gastric vessels around the fundus were similarly divided when performing sleeve gastrectomy. Adhesions between the anterior face of the pancreatic head and the posterior wall of the duodenal bulb were carefully dissected for full exposure of the pyloric ring. The gastrohepatic ligament was opened along the avascular plane, and the right gastric artery was identified and divided. The duodenum was transected with an endo GIA™ (Covidien, Mansfield, MA, USA). After checking the left gastric artery for anatomical variations, the main descending branch of the left gastric artery was divided with a LigaSure™ device (Covidien, Mansfield, MA, USA). Then, a small gastric pouch approximately 30 mL in volume was created along the lesser curvature using laparoscopic linear staplers, while carefully preserving the blood supply from the ascending branch of the left gastric artery to avoid pouch ischemia (Fig. 1). A gastrojejunal anastomosis was constructed using a linear stapler, and the entry hole of the stapler blades was hand-sewn closed. The Roux limb was positioned in an antecolic fashion. Afterward, a latero-lateral jejunojejunal anastomosis was established, with a 40-cm biliopancreatic limb and a 70-cm alimentary limb. All mesenteric defects were closed with non-absorbable suture materials. The stomach specimen was retrieved via an umbilical port site after extending the original incision. Postoperative management and data collection A prospectively established database and the medical records were retrospectively reviewed to analyze the preoperative demographics and surgical outcomes. The assessment of intraoperative parameters included the length of the operation, amount of blood lost during the operation and the presence of intraoperative complications. The length of the operation was defined as the time from skin incision to wound closure. The postoperative hospital stay and complications were also assessed. Complications were additionally graded according to the Accordion Severity Grading System [11]. The absence of postoperative leakage or passage disturbance was confirmed by a contrast upper gastrointestinal study. Patients then initiated oral intake on the morning of
Surg Today
Fig. 1 The steps performed during the resectional RYGB. a, b Division of the omentum along the whole length of the greater curvature, c ligation of the right gastric artery, d transection at the first portion
of the duodenum, e verification of the anatomical orientation of the left gastric artery, f, g division of the main descending branch of the left gastric artery, h creation of a small gastric pouch
the first postoperative day. Patients were discharged once they achieved adequate oral intake, their pain was under control and they were walking without difficulty. The
postoperative nutritional regimen consisted of a liquid or soft diet for the first three weeks, with a gradual expansion of the food texture thereafter. Patients returned to the
13
outpatient clinic two weeks after surgery and every three months thereafter for the first postoperative year to monitor weight loss, appetite, dysphagia or food intolerance, eating behavior, the comorbidity status and the presence of any complications. After the first year, the follow-up frequency was decreased to every 12 months. Patients who could not visit the outpatient clinic were monitored by telephone interview. The degree of weight loss was assessed based on the percent of excess weight loss (%EWL) and the percent of excess BMI loss (%EBMIL) [12]. The ideal weight calculated by the formula corresponding to the mid-point of the medium frame of the Metropolitan Tables was used to assess the %EWL [13]. The %EBMIL was calculated using a BMI of 23 kg/m2 as the upper limit of normal according to the World Health Organization (WHO) recommended definition of obesity for Asians [14].
Surg Today Table 1 The patient demographics and comorbidities (n = 16) Age (years) Sex Male Female Body weight (kg) BMI (kg/m2) Comorbidities Diabetes Hypertension Dyslipidemiaa Obstructive sleep apnea Obesity-related arthropathy PCOS Presence of H. pylorib
41 (25–58) 0 16 95.0 (66.0–137.0) 36.9 (26.4–51.6) 5 3 10 0 1 3 7 (43.8)
Figures are presented as the medians (range) or the number of patients BMI body mass index, PCOS polycystic ovarian syndrome
Results A total of 16 patients underwent resectional RYGB during the study period. The detailed demographic data of these patients are shown in Table 1. All patients were female and their mean BMI was 36.9 kg/m2 (range 26.4–51.6). Of the 16 patients, 13 (81.3 %) had at least one obesity-related comorbidity at the preoperative evaluation. The most frequently encountered obesity-related comorbidity was dyslipidemia (10/16, 62.5 %). Seven patients (43.8 %) were proven to be positive for Helicobacter pylori infection before the surgery. The perioperative surgical outcomes of these patients are shown in Table 2. The mean length of the operation time and hospital stay were 170 min (range 110–225) and 4 days (range 2–7), respectively. There was no laparotomic conversion and all procedures were successfully performed laparoscopically. Early postoperative complications developed in three patients (18.7 %). Detailed information on the postoperative complications following resectional RYGB is shown in Table 3. All early complications, which occurred within one month after surgery, were related to immediate postoperative bleeding. Among the two patients who presented with intra-abdominal bleeding, one showed unstable vital signs with evident ongoing bleeding through a closed drain immediately after the surgery and required urgent reoperation for hemostasis. The other showed sanguineous drainage via a closed drain, as well as a hemoglobin drop of 2.1 g/dL over 24 h on the first postoperative day. The patient was closely observed without any intervention or transfusion and was discharged on the seventh postoperative day when further bleeding was no longer evident. One patient manifested melena on the second postoperative day with a hemoglobin drop of
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a Definition of dyslipidemia: total cholesterol ≥240 mg/dL, LDL-C ≥160 mg/dL or HDL-C
