Surg Today DOI 10.1007/s00595-015-1170-y
ORIGINAL ARTICLE
Laparoscopic Roux‑en‑Y gastric bypass in obese Korean patients: efficacy and potential adverse events Ji Yeon Park1 · Yong Jin Kim1
Received: 4 February 2015 / Accepted: 23 March 2015 © Springer Japan 2015
Abstract Purpose This study aimed to evaluate the medium-term efficacy and adverse events of laparoscopic Roux-en-Y gastric bypass (LRYGB) performed at a single center in Korea. Methods The records of 412 consecutive patients who underwent LRYGB between January 2011 and February 2014 were retrospectively reviewed. The preoperative demographics, surgical outcomes, and follow-up data including anthropometrics indices and late complications were analyzed. Results The mean preoperative body mass index was 38.0 ± 5.8 kg/m2 and 338 patients (82.0 %) had at least one obesity-related comorbidity. Seven patients (1.7 %) developed severe complications requiring invasive intervention or reoperation. The %EWL of the eligible patients was 63.1, 74.3, 79.2, 65.4, and 89.8 % at 6, 12, 18, 24, and 36 months, respectively. Diabetes was resolved in 63.5 % of the followed up patients. Twenty-two out of 256 patients (8.6 %) with available follow-up data failed to achieve %EWL ≥50 % by 12 months after the surgery. The most frequent late complications were marginal ulcers (24.5 %) and anemia (18.0 %). Conclusion LRYGB achieves excellent weight loss and significant short- to medium-term comorbidity resolution in Korean obese patients with acceptable perioperative risks. However, late complications including marginal ulcers and nutritional deficiencies are not negligible. Therefore,
* Yong Jin Kim [email protected] 1
Department of Surgery, Soonchunhyang University Seoul Hospital, 59 Daesagwan‑ro, Yongsan‑gu, Seoul 140‑743, Republic of Korea
regular and lifelong surveillance is mandatory in patients undergoing LRYGB. Keywords Morbid obesity · Bariatric surgery · Rouxen-Y gastric bypass
Introduction The obese population is steadily increasing around the world and given the associated comorbidities, this trend imposes an enormous economic burden on general healthcare policy [1, 2]. Unfortunately, none of the currently available conservative methods, including diet, physical therapy, or medications, has succeeded in significantly relieving this burden in the long term. Currently, bariatric surgery is the most effective means to achieve marked and sustained weight loss, as well as improvements in various obesity-related comorbidities in the majority of morbidly obese patients [3]. It also reduces the utilization of various health services, which translates into significant medical cost savings [4]. Roux-en-Y gastric bypass (RYGB) has prevailed as the gold standard among various bariatric procedures for the last 50 years since it was first described by Mason and Ito [5]. The evolution of laparoscopic surgery has led to its gradual widespread use and laparoscopic RYGB (LRYGB) is currently the most commonly performed bariatric procedure in the world [6]. Although the application of laparoscopic sleeve gastrectomy (LSG) has rapidly increased in recent years and has shown the potential for achieving comparable weight loss with fewer complications, LRYGB will likely maintain its leading position until the long-term results of LSG become available. Nevertheless, experience with LRYGB in morbid obesity is relatively limited in the
13
Asia/Pacific region, particularly in East Asian countries [6]. As the incidence of morbid obesity is much lower in Asian countries than in Western countries, the necessity of surgical intervention to treat morbid obesity has only recently been recognized. In addition, a relatively low BMI in Asian obese patients compared to that in Western patients could represent another reason. Asian patients experience a satisfactory amount of weight loss through purely restrictive procedures such as laparoscopic adjustable gastric banding (LAGB) and LSG. These restrictive procedures are technically less demanding for relatively inexperienced Asian surgeons and are also associated with fewer concerns regarding long-term nutritional complications. However, studies have shown that the number of morbidly obese individuals is increasing in Asian countries, including South Korea [7]. LAGB or LSG may not be sufficient to achieve successful weight loss or may induce procedure-specific complications requiring revisional surgery as shown in our previous report [8]. Furthermore, Asian patients are known to be more vulnerable to various metabolic diseases, including those with low BMI. Although currently available literature from far-East Asia has shown promising results for LAGB and LSG in terms of weight loss and the resolution of comorbidities at least in the mid-term, it is necessary to diversify surgical modalities offered to provide the growing number of obese patients with more individualized options. However, there are only a few published reports available regarding the outcomes of LRYGB in these populations and most deal with small numbers of patients [9–13]. The present study aimed to evaluate the medium-term efficacy of LRYGB in morbidly obese patients at a single specialized institution in Korea and to investigate the characteristics of early and delayed postoperative complications.
Materials and methods The medical records of all consecutive patients who underwent LRYGB with primary intent at Soonchunhyang Hospital between January 2011 and February 2014 were retrospectively reviewed. The baseline, operative, and follow-up data from a prospectively established database were thoroughly reviewed and summarized. The approval for this review of hospital records was obtained from the institutional review board (SCHUH 2014-11-001) and the need for patient informed consent was waived. Bariatric surgery candidates were selected according to the International Federation for the Surgery of ObesityAsia Pacific Chapter Consensus statements in 2011 [14]. As such, patients with a body mass index (BMI) ≥30 kg/m2 with inadequately controlled obesity-related comorbidities (e.g., diabetes, obstructive sleep apnea, hypertension,
13
Surg Today
or obesity-related arthropathy) or with a BMI ≥35 kg/m2 were considered for bariatric surgery. The eligible patients were interviewed and thoroughly evaluated to identify any obesity-related conditions such as diabetes, cardiovascular diseases, and obstructive sleep apnea before the surgery. Patients with comorbid diseases were referred to the experts in each respective field for meticulous preoperative evaluation and management. Laboratory tests including liver and thyroid function tests, comprehensive metabolic study with lipid panel, and a nutritional assessment were carried out. Upper endoscopy was routinely performed to verify the presence of reflux disease or any gastric lesions. We generally offered the patients two types of procedures, laparoscopic sleeve gastrectomy (LSG) or LRYGB. The decision regarding the procedure type largely depended on the patients’ own selection following extensive discussion on the specific risks associated with each procedure. As an exception, LSG was prioritized in super-obese male patients (BMI > 50 kg/m2) with high surgical risks. The patients with a family history of gastric cancer or fear of cancer occurrence or hepatitis virus carriers with liver cirrhosis who might be eligible for liver transplantation were advised to undergo LSG rather than LRYGB. The patients received interdisciplinary education about the potential surgical and nonsurgical options, possible outcomes, possible complications, and necessary postoperative lifestyle changes and nutritional supplementation. Surgical procedures All operative procedures were performed laparoscopically by a single surgeon experienced in upper gastrointestinal surgeries. The patient was placed in a supine position with the surgeon and the scopist on the right and the assistant on the left. Six trocars were used to perform the LRYGB: one 11-mm port for a scope at the umbilicus, two 12-mm ports and three additional 5-mm ports were used (Fig. 1). The first trocar used to establish a pneumoperitoneum was typically placed in the left upper quadrant using the optical access method. After the left lateral lobe of the liver was lifted with a liver retractor to properly expose the His angle, careful dissection at the left esophagogastric junction was performed with a blunt dissector to facilitate the subsequent gastric resection. A small window was then created in the lesser omentum near the gastric wall at the lesser curvature beneath the insertion of the second branch of the left gastric artery. A laparoscopic linear stapler was introduced through the window and fired. One or two additional staples were applied toward the angle of His along the previously dissected space using a Goldfinger™ dissector (Johnson & Johnson Medical Products, Ethicon EndoSurgery, Cincinnati, OH, USA), creating a small gastric pouch of approximately 30 mL in volume. The greater
Surg Today
the first postoperative year to monitor weight loss, appetite, dysphagia or food intolerance, eating behavior, comorbidity status, and the presence of any complications. The follow-up frequency was then increased to every 12 months after the first year. Telephone interviews were also used to monitor the patients who could not visit the outpatient clinic. Follow‑up data analysis
Fig. 1 Trocar placement during laparoscopic Roux-en-Y gastric bypass (the arrow indicates the first trocar used to establish a pneumoperitoneum)
omentum and transverse colon were advanced to the upper abdomen to expose the ligament of Treitz. The most redundant portion of the proximal jejunum, which is approximately 30–50 cm from the ligament of Treitz, was raised near the gastric pouch in an antecolic fashion to establish the gastrojejunal anastomosis. When excessive tension at the anastomosis was expected, the greater omentum was opportunely divided to reduce the tension. A 15–20 mm sized gastrojejunal anastomosis was constructed using a linear stapler and the entry hole of the stapler blades was hand-sewn closed. The gastrojejunal anastomosis was occasionally reinforced when necessary. The jejunum was transected with a linear stapler to create a Roux limb while minimizing the length of the Roux limb left proximal to the gastrojejunostomy to avoid postoperative “candy-cane” Roux syndrome [15]. Subsequently, a latero-lateral jejunojejunal anastomosis was established using a 70–100 cm alimentary limb. All mesenteric defects were closed with nonabsorbable suture materials.
The degree of weight loss was assessed as the percent of excess weight loss (%EWL) calculated using the following formula: %EWL = [(preoperative weight − current weight)/(preoperative weight − ideal weight)] × 100. The ideal weight 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 [16]. The diagnosis of type 2 diabetes was made according to the criteria established by the American Diabetes Association [fasting blood glucose (FBS) ≥126 mg/dL or glycated hemoglobin A1c (HbA1c) level ≥6.5 %], while the criteria for diabetic remission were defined as FBS
ORIGINAL ARTICLE
Laparoscopic Roux‑en‑Y gastric bypass in obese Korean patients: efficacy and potential adverse events Ji Yeon Park1 · Yong Jin Kim1
Received: 4 February 2015 / Accepted: 23 March 2015 © Springer Japan 2015
Abstract Purpose This study aimed to evaluate the medium-term efficacy and adverse events of laparoscopic Roux-en-Y gastric bypass (LRYGB) performed at a single center in Korea. Methods The records of 412 consecutive patients who underwent LRYGB between January 2011 and February 2014 were retrospectively reviewed. The preoperative demographics, surgical outcomes, and follow-up data including anthropometrics indices and late complications were analyzed. Results The mean preoperative body mass index was 38.0 ± 5.8 kg/m2 and 338 patients (82.0 %) had at least one obesity-related comorbidity. Seven patients (1.7 %) developed severe complications requiring invasive intervention or reoperation. The %EWL of the eligible patients was 63.1, 74.3, 79.2, 65.4, and 89.8 % at 6, 12, 18, 24, and 36 months, respectively. Diabetes was resolved in 63.5 % of the followed up patients. Twenty-two out of 256 patients (8.6 %) with available follow-up data failed to achieve %EWL ≥50 % by 12 months after the surgery. The most frequent late complications were marginal ulcers (24.5 %) and anemia (18.0 %). Conclusion LRYGB achieves excellent weight loss and significant short- to medium-term comorbidity resolution in Korean obese patients with acceptable perioperative risks. However, late complications including marginal ulcers and nutritional deficiencies are not negligible. Therefore,
* Yong Jin Kim [email protected] 1
Department of Surgery, Soonchunhyang University Seoul Hospital, 59 Daesagwan‑ro, Yongsan‑gu, Seoul 140‑743, Republic of Korea
regular and lifelong surveillance is mandatory in patients undergoing LRYGB. Keywords Morbid obesity · Bariatric surgery · Rouxen-Y gastric bypass
Introduction The obese population is steadily increasing around the world and given the associated comorbidities, this trend imposes an enormous economic burden on general healthcare policy [1, 2]. Unfortunately, none of the currently available conservative methods, including diet, physical therapy, or medications, has succeeded in significantly relieving this burden in the long term. Currently, bariatric surgery is the most effective means to achieve marked and sustained weight loss, as well as improvements in various obesity-related comorbidities in the majority of morbidly obese patients [3]. It also reduces the utilization of various health services, which translates into significant medical cost savings [4]. Roux-en-Y gastric bypass (RYGB) has prevailed as the gold standard among various bariatric procedures for the last 50 years since it was first described by Mason and Ito [5]. The evolution of laparoscopic surgery has led to its gradual widespread use and laparoscopic RYGB (LRYGB) is currently the most commonly performed bariatric procedure in the world [6]. Although the application of laparoscopic sleeve gastrectomy (LSG) has rapidly increased in recent years and has shown the potential for achieving comparable weight loss with fewer complications, LRYGB will likely maintain its leading position until the long-term results of LSG become available. Nevertheless, experience with LRYGB in morbid obesity is relatively limited in the
13
Asia/Pacific region, particularly in East Asian countries [6]. As the incidence of morbid obesity is much lower in Asian countries than in Western countries, the necessity of surgical intervention to treat morbid obesity has only recently been recognized. In addition, a relatively low BMI in Asian obese patients compared to that in Western patients could represent another reason. Asian patients experience a satisfactory amount of weight loss through purely restrictive procedures such as laparoscopic adjustable gastric banding (LAGB) and LSG. These restrictive procedures are technically less demanding for relatively inexperienced Asian surgeons and are also associated with fewer concerns regarding long-term nutritional complications. However, studies have shown that the number of morbidly obese individuals is increasing in Asian countries, including South Korea [7]. LAGB or LSG may not be sufficient to achieve successful weight loss or may induce procedure-specific complications requiring revisional surgery as shown in our previous report [8]. Furthermore, Asian patients are known to be more vulnerable to various metabolic diseases, including those with low BMI. Although currently available literature from far-East Asia has shown promising results for LAGB and LSG in terms of weight loss and the resolution of comorbidities at least in the mid-term, it is necessary to diversify surgical modalities offered to provide the growing number of obese patients with more individualized options. However, there are only a few published reports available regarding the outcomes of LRYGB in these populations and most deal with small numbers of patients [9–13]. The present study aimed to evaluate the medium-term efficacy of LRYGB in morbidly obese patients at a single specialized institution in Korea and to investigate the characteristics of early and delayed postoperative complications.
Materials and methods The medical records of all consecutive patients who underwent LRYGB with primary intent at Soonchunhyang Hospital between January 2011 and February 2014 were retrospectively reviewed. The baseline, operative, and follow-up data from a prospectively established database were thoroughly reviewed and summarized. The approval for this review of hospital records was obtained from the institutional review board (SCHUH 2014-11-001) and the need for patient informed consent was waived. Bariatric surgery candidates were selected according to the International Federation for the Surgery of ObesityAsia Pacific Chapter Consensus statements in 2011 [14]. As such, patients with a body mass index (BMI) ≥30 kg/m2 with inadequately controlled obesity-related comorbidities (e.g., diabetes, obstructive sleep apnea, hypertension,
13
Surg Today
or obesity-related arthropathy) or with a BMI ≥35 kg/m2 were considered for bariatric surgery. The eligible patients were interviewed and thoroughly evaluated to identify any obesity-related conditions such as diabetes, cardiovascular diseases, and obstructive sleep apnea before the surgery. Patients with comorbid diseases were referred to the experts in each respective field for meticulous preoperative evaluation and management. Laboratory tests including liver and thyroid function tests, comprehensive metabolic study with lipid panel, and a nutritional assessment were carried out. Upper endoscopy was routinely performed to verify the presence of reflux disease or any gastric lesions. We generally offered the patients two types of procedures, laparoscopic sleeve gastrectomy (LSG) or LRYGB. The decision regarding the procedure type largely depended on the patients’ own selection following extensive discussion on the specific risks associated with each procedure. As an exception, LSG was prioritized in super-obese male patients (BMI > 50 kg/m2) with high surgical risks. The patients with a family history of gastric cancer or fear of cancer occurrence or hepatitis virus carriers with liver cirrhosis who might be eligible for liver transplantation were advised to undergo LSG rather than LRYGB. The patients received interdisciplinary education about the potential surgical and nonsurgical options, possible outcomes, possible complications, and necessary postoperative lifestyle changes and nutritional supplementation. Surgical procedures All operative procedures were performed laparoscopically by a single surgeon experienced in upper gastrointestinal surgeries. The patient was placed in a supine position with the surgeon and the scopist on the right and the assistant on the left. Six trocars were used to perform the LRYGB: one 11-mm port for a scope at the umbilicus, two 12-mm ports and three additional 5-mm ports were used (Fig. 1). The first trocar used to establish a pneumoperitoneum was typically placed in the left upper quadrant using the optical access method. After the left lateral lobe of the liver was lifted with a liver retractor to properly expose the His angle, careful dissection at the left esophagogastric junction was performed with a blunt dissector to facilitate the subsequent gastric resection. A small window was then created in the lesser omentum near the gastric wall at the lesser curvature beneath the insertion of the second branch of the left gastric artery. A laparoscopic linear stapler was introduced through the window and fired. One or two additional staples were applied toward the angle of His along the previously dissected space using a Goldfinger™ dissector (Johnson & Johnson Medical Products, Ethicon EndoSurgery, Cincinnati, OH, USA), creating a small gastric pouch of approximately 30 mL in volume. The greater
Surg Today
the first postoperative year to monitor weight loss, appetite, dysphagia or food intolerance, eating behavior, comorbidity status, and the presence of any complications. The follow-up frequency was then increased to every 12 months after the first year. Telephone interviews were also used to monitor the patients who could not visit the outpatient clinic. Follow‑up data analysis
Fig. 1 Trocar placement during laparoscopic Roux-en-Y gastric bypass (the arrow indicates the first trocar used to establish a pneumoperitoneum)
omentum and transverse colon were advanced to the upper abdomen to expose the ligament of Treitz. The most redundant portion of the proximal jejunum, which is approximately 30–50 cm from the ligament of Treitz, was raised near the gastric pouch in an antecolic fashion to establish the gastrojejunal anastomosis. When excessive tension at the anastomosis was expected, the greater omentum was opportunely divided to reduce the tension. A 15–20 mm sized gastrojejunal anastomosis was constructed using a linear stapler and the entry hole of the stapler blades was hand-sewn closed. The gastrojejunal anastomosis was occasionally reinforced when necessary. The jejunum was transected with a linear stapler to create a Roux limb while minimizing the length of the Roux limb left proximal to the gastrojejunostomy to avoid postoperative “candy-cane” Roux syndrome [15]. Subsequently, a latero-lateral jejunojejunal anastomosis was established using a 70–100 cm alimentary limb. All mesenteric defects were closed with nonabsorbable suture materials.
The degree of weight loss was assessed as the percent of excess weight loss (%EWL) calculated using the following formula: %EWL = [(preoperative weight − current weight)/(preoperative weight − ideal weight)] × 100. The ideal weight 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 [16]. The diagnosis of type 2 diabetes was made according to the criteria established by the American Diabetes Association [fasting blood glucose (FBS) ≥126 mg/dL or glycated hemoglobin A1c (HbA1c) level ≥6.5 %], while the criteria for diabetic remission were defined as FBS
