Open Bariatric Surgery Research Articles

P103: Intra-rectus mesh hernia repair following Roux-en-Y gastric bypass

Ventral hernia following open bariatric surgery remains a clinical problem. We report our experience with a 3-layer mesh interposition hernia repair that places the mesh within the confines of the rectus. This repair is a modification of the repair originally described by Stoppa, which does not use lateral trans-fascial anchoring sutures.

A Comparison of Wedge and Needle Hepatic Biopsy in Open Bariatric Surgery

Morbidly obese patients, despite normal laboratory tests and no clinical evidence of liver disease, present a high prevalence of hepatic histological changes. Liver biopsy is able to provide the diagnosis, staging and assessment of follow-up of hepatic disease, thus helping to define clinical management. There is no agreement on which biopsy technique provides better material for analysis. Considering that subcapsular fibrosis is a common finding, sampling from deeper sites is necessary to achieve an adequate histological assessment. A study was done in 264 consecutive morbidly obese patients who underwent open Roux-en-Y gastric bypass between July 2001 and Sept 2004, in whom an intraoperative liver biopsy was taken. The first 107 were wedge biopsies, and the last 157 were needle biopsies. The histological degree of steatosis, presence of fibrosis and adequacy of material from the 2 biopsy techniques were compared. Degree of steatosis in both sampling techniques showed no statistical difference (P=0.132). The presence of fibrosis in wedge biopsies (46.1% fibrosis, n 41) was significantly higher than in needle biopsies (13.7% fibrosis, n 20), P<0.001. As expected, sample size of needle biopsies was smaller than that obtained by the wedge technique (P<0.001), but there was no difference in the quality of material obtained (P=0.95). Needle biopsies were as effective as wedge biopsies in assessing the degree of steatosis in morbidly obese patients. More important, the presence of subcapsular fibrosis in needle biopsies was less than in wedge biopsies, suggesting an adequate tissue sample by the less invasive technique.

Accelerated Growth of Bariatric Surgery With the Introduction of Minimally Invasive Surgery

An increase in national utilization of bariatric surgery correlates with the dissemination of laparoscopic bariatric surgery. Evaluation of Nationwide Inpatient Sample data from 1998 through 2002. National database. A total of 188,599 patients underwent bariatric surgery for the treatment of morbid obesity. Annual total number of bariatric operations, the proportion of Roux-en-Y gastric bypass vs gastroplasty, the proportion of laparoscopic cases, postoperative length of stay, crude in-hospital mortality, and the number of institutions that perform bariatric surgery. Between 1998 and 2002, the number of bariatric operations increased from 12,775 cases to 70,256 cases. The rate of bariatric surgery increased from 6.3 to 32.7 procedures per 100,000 adults. Laparoscopic bariatric surgery increased from 2.1% to 17.9%. The number of bariatric surgeons with membership in the American Society for Bariatric Surgery increased from 258 to 631, and the number of institutions that perform bariatric surgery increased from 131 to 323. During this 5-year period, the annual rate of laparoscopic bariatric surgery increased exponentially (by 44-fold) compared with a linear growth in open bariatric surgery (by 3-fold). Between 1998 and 2002, there was a 450% increase in the number of bariatric operations performed in the United States, a 144% increase in the number of American Society for Bariatric Surgery bariatric surgeons, and a 146% increase in the number of bariatric centers. The growth of laparoscopic bariatric surgery during this 5-year period greatly exceeds that of open bariatric surgery.

Review of technique for combined closed incisional hernia repair and panniculectomy status post–open bariatric surgery

Background After open bariatric surgery, many patients develop incisional hernia. Patients who were once morbidly obese provide a unique challenge to hernia repair, given the larger nature of their fascial defects and the concomitant problem of extreme amounts of abdominal wall laxity. We reviewed a technique for surgical repair of incisional hernias combined with panniculectomy. Methods A retrospective review of 50 consecutive patients status post–open bariatric surgery who underwent incisional hernia repair with overlay mesh and combined panniculectomy between 2000 and 2003. Results Hernia repair and panniculectomy were performed 18 months after open bariatric surgery. The patients had an average weight loss of 58.6 kg. Mean follow-up after hernia repair and panniculectomy was 18 months. Patients underwent prefascial hernia repair with plication of the fascial edges followed by midline anchoring of overlay mesh. The averave amount of excess tissue excised via panniculectomy was 3001 g. The average hospital stay was 4 days. Minor wound problems (eg, suture abscess, seroma) occurred in 20 patients. Seromas were treated with serial aspiration in the office. There were no intra-abdominal complications or recurrences of the incisional hernias. Conclusion Closed hernia repair with prefascial plication and overlay mesh is a safe, effective alternative to traditional incisional hernia repair. It provides adequate hernia repair without recurrence and eliminates intra-abdominal complications. It is our belief that combining the hernia repair and panniculectomy minimizes the risk of hernia recurrence through alleviation of stress on the repair by removing excess abdominal wall tissue.

Open Bariatric Surgery Is Preferable to a Two-Stage Laparoscopic Approach

Open Bariatric Surgery Is Preferable to a Two-Stage Laparoscopic Approach

The Optimal Surgical Management of the Super Obese Patient: The Debate

Optimal management of the super-obese patient (body mass index>50 kg/m2) undergoing weight loss surgery in the new era of laparoscopic treatment is more controversial than ever before. Newer laparoscopic options for treatment of the super obese, including laparoscopic adjustable gastric banding, sleeve gastrectomy, and staging of gastric bypass, are technically easier and may be safer. Concerns that weight loss may be suboptimal or that the procedures will require revision, or both, make these choices controversial. Open access/conversion for established procedures such as long-limb gastric bypass and biliopancreatic diversion with or without duodenal switch are the traditional alternatives when laparoscopic access fails or is deemed too difficult to undertake. The following debate was presented by invited experts in laparoscopic and open bariatric surgery at the 2005 Annual Meeting of the Society of American Gastrointestinal and Endoscopic Surgeons in Florida. The presenters put forth arguments for the various modern options for treatment of the super obese, which are presented in written form. Interactive audience response technology provided a mechanism for polling the audience before and after the presentations. A review of the audience's responses provides insight into the decision-making considerations of a population of laparoscopically oriented bariatric surgeons.

The impact of laparoscopy on bariatric surgery

The rising popularity of bariatric surgery over the past several years is attributable in part to the development of laparoscopic bariatric surgery. Morbidly obese patients have associated comorbid conditions that may predispose them to postoperative morbidity. The laparoscopic approach to bariatric surgery offers a minimally invasive option that reduces the physiologic stress and provides clinical benefits, as compared with the open approach. This review summarizes the impact of laparoscopic surgery on bariatric surgery, the various risk factors that could potentially predispose morbidly obese patients to postoperative morbidity, the fundamental differences between laparoscopic and open bariatric surgery, and the physiology of reduced tissue injury associated with laparoscopic bariatric surgery.

Singapore Experience in Obesity Surgery

The outcome of bariatric surgery has been well documented in large series in the West. In Asia, where obesity has been less rampant, such surgery has been correspondingly less frequent, and there is a dearth of information on bariatric surgery on Asians. The outcome of a personal series of 40 patients who underwent "gastric stapling" and banding from 1987 to 2003 in Singapore is analyzed. From 1987 to 1997, 26 patients underwent open bariatric surgery (Roux-en-Y gastric bypass 4, vertical banded gastroplasty 22). Initial mean BMI was 43.3 kg/m2. At 0.6, 1, 2, 4 and 8 years after surgery, mean BMI was 35.2, 31.9, 31.2, 31.1 and 34.1 kg/m2. Mean initial weight was 127.2 kg. %EWL was 42.2, 56.2, 56.9, 56.3 and 48.3%. From 1999 to 2003, 14 patients underwent adjustable gastric banding, 11 by laparoscopy. Initial mean BMI was 42.9 kg/m2. At 0.6, 1 and 2 years, mean BMI was 38.9, 36.6, and 32.6 kg/m2. Mean initial weight was 122.6 kg. %EWL was 26.6, 38.8 and 59.2%. One patient, following perigastric insertion of Lap-Band developed band slippage and gastric prolapse requiring removal. Since adopting the newer technique of combined pars flaccida and perigastric dissection in the last 6 patients, no band slippage has occurred. Our results of safety and low operative morbidity as well as the pattern and magnitude of weight loss following gastric stapling and banding for morbidly obese patients in Singapore appears to be similar to the Western experience.

Analysis of the incidence and risk factors for wound infections in open bariatric surgery.

Our clinical impression derived from >95% follow-up of patients was that our wound infection rate was higher than the 1-10% reported in the literature. The purpose of this study was to determine the incidence and risk factors for wound infection in open bariatric surgery. We queried our prospectively acquired bariatric surgery outcomes database, and retrospectively audited the charts of patients operated from April 1 to March 31, 2003. Risk categories were obtained using the National Nosocomial Infection Surveillance (NNIS) definitions and stratification. Expected site-specific rates were adjusted for duration of operation, degree of wound contamination, and underlying disease condition. 269 patients undergoing a standardized open Roux-en-Y gastric bypass were studied. The mean age (SD) was 39.5 (10.5) years and the mean BMI was 54.3 (9.9). Operating time averaged 63 (17) minutes, and length of stay was 4.1 (1.3) days. Based on NNIS categories 10.9 wound infections were expected, but 54 were observed, for a rate of 20%. Bacterial isolates included S. aureus (39%), alpha-hemolytic strep (26%), Enterococcus (16%), P.mirabilis (9%), and multiple other bacteria at 10%. Epidural analgesia and delayed antibiotic prophylaxis administration (after the incision was made) increased the odds of developing a wound infection, whereas gender, age, BMI, duration of surgery, and incidence of diabetes had no effect. There was a high correlation between wound infection and subsequent incisional hernia formation. The incidence of wound infections following open bariatric surgery is high, and the current recommendations for antibiotic prophylaxis are ineffective. As these infections carry significant morbidity, effective methods to prevent them are needed.

Small bowel obstruction and internal hernias after laparoscopic Roux-en-Y gastric bypass.

Small bowel obstruction (SBO) is a recognized complication of open bariatric surgery; however, the incidence after laparoscopic procedures is not clearly established. This paper reviews our experience with small bowel obstruction after laparoscopic Roux-en-Y gastric bypass. Between 1995 and 2001, 711 (246 antecolic, 465 retrocolic) patients underwent a laparoscopic proximal divided Roux-en-Y gastric bypass via the linear endostapler technique. 13 patients (1.8%) developed SBO requiring surgical intervention. There were 11 females and 2 males, ages 29-60 (mean 38), with mean weight 126 kg (range 105-188), and mean BMI 50 (range 41-59). 7 obstructive patients (55%) had undergone previous open abdominal surgery. Median time to obstruction was 21 days (range 5-1095). Mean follow-up of all patients is 43 months (range 3-79). Etiology of obstruction was internal hernia - 6, adhesive bands - 5 (only 2 were related to prior open surgery), mesocolon window scarring - 1, and incarcerated ventral hernia - 1. The incidence of SBO was 4.5% (11/246) in the retrocolic group, and 0.43% (2/465) in the antecolic group, which was highly significant (P=.006). 1 adhesive patient required an open bowel resection for ischemia. There was 1 death. SBO occurred with an overall incidence of 1.8% in a large series of laparoscopic gastric bypass patients, and was associated with a high morbidity. A significant decrease in occurrence was found after adoption of antecolic placement of the Roux limb.

Our experience with 250 laparoscopic adjustable silicone gastric bandings.

In 1999, after having performed more than 2500 open bariatric surgery procedures, we began to conduct the laparoscopic adjustable silicone gastric banding (LASGB) procedure. The purpose of this report is to present the results of our first 250 operations using this technique. The 250 patients included 212 females and 38 males. The mean age was 36 years (range, 16-62). The mean BMI was 44 (range, 35-76). Patients were selected in accordance with standard criteria. The mean follow-up time was 18 months (range, 3-24). Two hundred and forty procedures were completed by laparoscopy; conversion to open surgery was required in 10 cases. The mean operating time was 50 min (range, 20-145). There was no mortality. Perioperative complications included two cases of gastric perforation. Late complications included 13 cases of band slippage (5%), of which three involved penetration to the stomach, five cases of port disconnection (2%), and four cases of port site infection (1.5%). The mean weight loss at 12 months was 70% of the original excess weight. Most patients prefer laparoscopy as the surgical technique in the treatment of morbid obesity. Our initial experience with 250 operations confirms that this approach is as good as open surgery. The long learning curve is steep, requiring at least 100 cases to guarantee low complication rates.

Anesthetic Considerations for Bariatric Surgery

According to the National Institutes of Health, obesity is a major health problem with clearly established health implications, including an increased risk for coronary artery disease, hypertension, dyslipidemia, diabetes mellitus, gallbladder disease, degenerative joint disease, obstructive sleep apnea, and socioeconomic and psychosocial impairment (1). The risk of developing one or more of these obesityrelated conditions is based on body mass index (BMI), with 25–30 kg/m 2 being low risk and 40 kg/m 2 being very high risk (2). The prevalence of obesity in the 18- to 29-yr-old group increased from 12% in 1991 to 18.9% in 1999 (3). Bariatric surgery encompasses a variety of surgical weight loss procedures used to treat morbid obesity. Obesity is clinically expressed in terms of BMI or Quetelet’s index (4), which is derived by dividing weight by the square of height to estimate the degree of obesity. Thus, BMI body weight (kg)/height 2 (m 2 ). Morbid obesity is a BMI more than 35 kg/m 2 , and super morbid obesity is BMI more than 55 kg/m 2 . The indications for surgical treatment of severe obesity, as outlined in the 1991 National Institutes of Health Consensus Development Conference Panel, include an absolute BMI more than 40 kg/m 2 or BMI more than 35 kg/m 2 in combination with lifethreatening cardiopulmonary problems or severe diabetes mellitus (1). Patients seeking surgical weight loss must have proven attempts at medically supervised weight loss. Documentation of loss of 5% to 10% excess body weight or weight gain after at least 6 mo of diet modification, exercise, and medical therapy or nonimprovement in comorbid conditions during this period indicates failure. Studies have shown that weight loss of 5%–10% of initial body weight improves glucose intolerance and Type II diabetes, hypertension, and dyslipidemia (5–7). The average expenditure is approximately $7000 per year per patient on weight loss programs and equipment. Unfortunately, long-term weight loss is the exception, and most patients regain weight, sometimes more than they initially lost.

LAPAROSCOPIC BARIATRIC SURGERY

At present, laparoscopic bariatric surgery is a controversial topic among bariatric and laparoscopic surgeons. Although difficult to perform, the traditional procedures used for treating severe obesity are now being performed successfully using a laparoscopic approach. In addition, a new procedure, adjustable gastric banding, has been used in Europe; however, it lacks US Food and Drug Administration approval and adequate scientific follow-up data about long-term effectiveness. Appropriate patient selection and adherence to the principles that have been learned by experience through open bariatric surgery remain of paramount importance for the success of laparoscopic bariatric operations.

Laparoscopic Placement of Adjustable Silicone Gastric Band in the Treatment of Morbid Obesity: How to Do It.

BACKGROUND: laparoscopic placement of the adjustable silicone gastric band (ASGB) was begun in our institution in 1992. METHODS: this work started on the animal model first. In the animal laboratory, details of laparoscopic dissection around the pig's stomach were defined. A new prototype of the adjustable silicone band for laparoscopic use was devised. The first human laparoscopic ASGB procedure was performed in our institution on September 1, 1993; 37 patients have undergone this operation by May, 1994. There were 33 women and four men. The average pre-operative weight was 114 kg (92160 kg). The mean BMI was 42 kg m(2) (37-50 kg m(2)). RESULTS: no major operative difficulty has been encountered. Immediate post-operative outcome was uneventful except for one patient. CONCLUSION: the technique of laparoscopic ASGB is described. Preliminary weight loss is comparable to open ASGB and vertical gastroplasty, provided that the surgeon has mastered laparoscopy and open bariatric surgery.