Laparoscopic verses open gastric bypass to treat morbid obesity.

Abstract

I am pleased to comment on the third prospective randomized comparison of laparoscopic versus open Roux-en-Y gastric bypass (RYGB) for treatment of morbid obesity in the world literature. The authors’ findings are similar to those of the first 2 prospective randomized comparisons performed at U.C. Davis Medical Center and Uppsala, Sweden, respectively.1–3 A comparison of features between the Spanish and American randomized studies along with several other large cohort studies of laparoscopic gastric bypass is shown in Table 1.4–6 There was a significant difference in the mean operative time in each of the randomized studies. However, in the Spanish study the mean time in performing open procedures was significantly greater; conversely, in the American study the laparoscopic operative time was significantly greater in comparison with the open time. There was an 8% conversion rate in the Spanish study versus a 2.5% conversion rate in the American study. One of the conversions was in a patient with portal hypertension in whom the operation likely should have been aborted rather than converted. Early complication rates between the Spanish and American studies were quite different. However, there was no significant difference in the early morbidity rate between the laparoscopic and open techniques within each randomized study. The nature of early complications was fairly typical in the 2 randomized series, though the Spanish laparoscopic series had a relatively high rate of hemmorhagic sequelae (3 GI and 2 intra-abdominal), which comprised 42% of their early complications. There were 3 early jejunojejunostomy obstructions (3.7%) in the American laparoscopic series versus none in the Spanish study. There were no deaths in the laparoscopic group and 1 death following open RYGB in the Spanish series versus no mortality in the American series. TABLE 1. Comparison of Selected Series of Laparoscopic RY Gastric bypass There was a significantly greater incidence of late complications following open RYGB in the Spanish series, whereas in the American series there was no significant difference in the overall late complication rate between laparoscopic and open RYGB. However, there was a significantly higher incidence of incisional hernias following open procedures in the American series. Although incisional hernias also comprised the preponderance of late complications in the Spanish series, the difference in hernia rate between open and laparoscopic RYGB was not significant. Weight selection criteria in the American and Spanish series were somewhat different in that the Spanish series had no upper BMI limit for inclusion, whereas the American series did not include patients with a BMI greater than 60 kg/m2. The overall costs in the American series were similar between the laparoscopic and open groups, though the cost distribution was quite different. The equipment related costs for laparoscopy are significantly higher versus the open approach. This high up-front cost, however, is offset by the longer length of stay (LOS) following open RYGB. Mean hospital LOS was significantly greater following open operations in both the American and Spanish series. The mean LOS in the American series is more than 1 day less versus the Spanish series, with a lesser difference in mean LOS between the open groups. Comparison of the results of these 2 randomized studies to those of other large cohort studies of laparoscopic RYGB are shown in the Table. Many of the larger published series of laparoscopic RYGB cases extend well beyond the so-called learning curve that is frequently discussed in the context of performing this complex, minimally invasive procedure. Conversely, both of the prospective randomized comparisons likely included laparoscopic surgeons who were in the midst of their learning curves. The 8% conversion rate in the Spanish series supports that premise. The learning curve may also have contributed to the longer operative time of the open procedures in the Spanish series. The surgeon who performed the open operations in the American series had many years of experience, which probably explains why his mean operative time was significantly lower than that of his laparoscopic colleague. It is likely that the operative time and early morbidity rate for laparoscopic gastric bypass will decrease substantially at the end of the learning curve. There were no substantial differences in operative technique between the 2 randomized studies. RYGB in both of the prospective series and Schauer's early experience was performed using a retrocolic Roux limb and a gastrojejunostomy created with a circular stapler. A retrocolic Roux limb and linear stapled gastrojejunostomy was used in the DeMaria series, whereas the Mt. Sinai group5 used an antecolic Roux limb and circular stapled gastrojejunostomy. Some bariatric surgeons believe that stomal stenosis is more common after a circular stapled anastomosis. Others believe that small bowel obstruction caused by internal hernia is more common using a retrocolic Roux limb. A comprehensive review of 18 recently published cohort studies (10 laparoscopic, 8 open) showed significant differences between the laparoscopic and open techniques, generally favoring laparoscopy.7 The authors’ conclusions were that the laparoscopic approach offered several advantages versus the open technique, including a significantly shorter length of hospital stay and incidence of postoperative abdominal wall hernias. These 2 findings have been consistent throughout the published literature. The mortality rate and wound infection rate in the combined cohort experience was significantly lower after laparoscopic versus open gastric bypass. However, this difference appears to be lost in comparing smaller series of operations performed at the same institution. Conversely, the open approach had a significantly lower incidence of late stomal stenosis and bowel obstruction in the combined cohort series. The incidence of early GI tract hemorrhage also favored the open approach at a level that approached significance. It is my belief that the greatest beneficiary of laparoscopic RYGB is the bariatric patient. After more than 20 years of guiding patients through the occasionally perilous perioperative period after open RYGB, I derive great pleasure from seeing my patients walking in the hallways 1 day after undergoing laparoscopic RYGB and writing the discharge order on postoperative day 2. Laparoscopy is a major advance in the field of bariatric surgery. The authors are to be congratulated on performing this prospective randomized comparison in a challenging group of patients.