The effect of transecting vs. stapling the stomach in continuity in the banded gastric bypass (GBP) operation was studied.
50 patients, 25 in each group, were enrolled into a prospective study to determine if transecting the stomach vs. stapling it in continuity in performing GBP for obesity decreases the incidence of gastro-gastric fistula formation without increased morbidity.
The patient profiles in the 2 groups were very similar. The peri-operative complications included 1 splenic capsular injury in each group, controlled without a splenectomy. There was 1 anastomotic leak in the stapled and 1 bleeding from the cut edge of the bypassed stomach in the transected group, both requiring re-operations in the immediate postoperative period. There was no peri-operative mortality. The percent follow-up after 6 years was 80% and 88% in the stapled and transected groups respectively. The incidence of late complications of solid food intolerance, ventral incisional hernia, cholelithiasis and small bowel obstruction was similar in both groups. There were 8 gastro-gastric fistulas in the stapled group and 1 in the transected group. The reduction in body mass index and percent excess weight loss (66%) were similar in both groups.
The incidence of gastro-gastric fistula may be reduced in GBP procedures by transecting the stomach as opposed to stapling it in continuity, without an increase in morbidity or mortality or any loss in the effectiveness of the operation.
"Among the hypotheses to explain weight regain, one is that it may occur as a consequence of pouch enlargement or dilation of the gastrojejunostomy. Linner, Fobi, and Capella, among others, have suggested reinforcement of either the pouch or the anastomosis with a prosthetic material to avoid the risk of dilation and to maintain the weight loss   . "
[Show abstract][Hide abstract] ABSTRACT: Background:
Banded Roux-en-Y gastric bypass was designed to avoid or diminish weight regain in the long term. In 2008, we published the initial results of a pilot study design to comparatively evaluate surgical morbidity, mortality, and maximum weight loss in patients undergoing banded and unbanded laparoscopic Roux-en-Y gastric bypass (LRYGB). The present study analyzes the 5-year results.
A randomized, controlled trial was carried out in 60 morbidly obese patients who underwent LRYGB. Patients were divided in 2 groups. Half of the patients underwent the banded version of the LRYGB, and half underwent the unbanded version. The 5-year excess weight loss (EWL) and loss of body mass index (BMI) were comparatively analyzed.
There were 58 females and 2 males with a mean preoperative BMI of 47±4.9 kg/m(2). A total of 21 patients with banded LRYGB and 22 with unbanded LRYGB completed 5-year follow-up. One patient died 3 years after surgery from metastatic melanoma. EWL at 5 years was 61.6%±19.6% versus 59.8%±15.9% (P = ns), and loss of BMI was 32.9%±5.2% versus 32.8%±4.3% (P = ns), respectively, for the banded and unbanded group.
In this small study, there were no statistical differences in the EWL and the BMI lost at 5 years between the group of patients who underwent banded and unbanded LRYGB.
Surgery for Obesity and Related Diseases 10/2012; 9(3). DOI:10.1016/j.soard.2012.09.009 · 4.07 Impact Factor
"In addition, we did not find any correlation between an elevated body mass index and leak formation and the eventual development of gastrogastric fistulas. Some authors have demonstrated that transecting the stomach, instead of stapling it in continuity, may decrease the incidence of gastrogastric fistulas normally seen in procedures such as the silastic ring gastric bypass and vertical band gastroplasty . Furthermore, Gould et al.  attributed their small incidence of gastrogastric fistulas to the incomplete division of the apical portion of the stomach during construction of the pouch and acknowledged the difficulty in the visualization of the angle of His during this step of the operation. "
[Show abstract][Hide abstract] ABSTRACT: Laparoscopic Roux-en-Y gastric bypass (RYGB) is the most commonly performed bariatric operation in the United States. Although rare, gastrogastric fistulas are an important complication of this procedure.
We report a series of 1,292 consecutive patients who underwent a divided RYGB procedure at our institution between January 2000 and November 2004. Of the 1,292 patients, we identified 15 (1.2%) who presented with gastrogastric fistulas after surgery.
The mean age, weight, and body mass index of these patients was 39.5 years, 377.5 lb, and 54.9 kg/m(2), respectively. The mean postoperative follow-up was 17.6 months. The overall follow-up success rate in this series at 1 and 2 years postoperatively was 85% and 77%, respectively. Of the 15 patients, 12 (80%) presented with symptoms of nausea, vomiting, and epigastric pain. Esophagogastroscopy revealed marginal ulcers in 8 (53%) of these symptomatic patients. The most sensitive test for the diagnosis of gastrogastric fistula was an upper gastrointestinal contrast study. The mean time to fistula diagnosis was 80 days. Four patients (27%) had had a known leak before their diagnosis of gastrogastric fistula. In all cases, the leaks were managed nonoperatively with drainage, parenteral nutrition, and bowel rest. In this subset of patients, the mean time to fistula diagnosis was 25 days. Four patients (27%) presented to the clinic unsatisfied with their weight loss. The mean excess percentage of weight loss was 60.9%. Of the 15 patients with a diagnosed gastrogastric fistula, 8 (53.3%) presented with concomitant marginal ulcers. When present, marginal ulcers were managed with chronic acid suppressive therapy consisting of proton pump inhibitors and sucralfate. Revisional surgery was performed in 5 (33.3%) of 15 patients because of the combination of constant pain and ulceration refractory to optimal medical treatment and in 1 patient (7%) because of refractory pain unresponsive to medical therapy and weight regain. All revisional procedures (100%) were performed laparoscopically.
Gastrogastric fistulas are an uncommon, but worrisome, complication after divided RYGB. Most symptoms of gastrogastric fistula are related to epigastric pain and ulcerations around the anastomotic site, but the fistula can occur anywhere along the divided segment of the gastric wall. They can initially be managed with a conservative, nonoperative approach as long as the patient remains asymptomatic and weight regain does not occur. Refractory ulcers and pain are the main indications for revisional surgery. Weight loss failure or weight regain is an uncommon short-term finding with gastrogastric fistulas after divided RYGB that requires surgical revision as the definitive treatment option. Although we present one of the largest series to date, longer follow-up is needed to better define the management of this patient population and provide a more accurate incidence of its occurrence.
Surgery for Obesity and Related Diseases 09/2005; 1(5):467-74. DOI:10.1016/j.soard.2005.07.003 · 4.07 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Laparoscopic adjustable gastric banding (LAGB) and laparoscopic Roux-en-Y gastric bypass (LRYGB) are the two most commonly performed bariatric procedures. Although both procedures likely reduce healthcare expenditures related to the resolution of co-morbid conditions, they have different rates of perioperative risks and different rates of associated weight loss. We designed a model to evaluate the incremental cost-effectiveness of these procedures compared with nonoperative weight loss interventions and with each other.
We used a deterministic, payer-perspective model comparing the lifetime expected costs and outcomes of LAGB, LRYGB, and nonoperative treatment. The major endpoints were survival, health-related quality of life, and weight loss. Life expectancy and lifetime medical costs were calculated across age, gender, and body mass index (BMI) strata using previously published data.
For both men and women, LRYGB and LAGB were cost-effective at <$25,000/quality-adjusted life-year (QALY) even when evaluating the full range of baseline BMI and estimates of adverse outcomes, weight loss, and costs. For base-case scenarios in men (age 35 y, BMI 40 kg/m(2)), the incremental cost-effectiveness was $11,604/QALY for LAGB compared with $18,543/QALY for LRYGB. For base-case scenarios in women (age 35 y, BMI 40 kg/m(2)), the incremental cost-effectiveness was $8878/QALY for LAGB compared with $14,680/QALY for LRYGB.
The modeled cost-effectiveness analysis showed that both operative interventions for morbid obesity, LAGB and RYGB, were cost-effective at <$25,000 and that LAGB was more cost-effective than RYGB for all base-case scenarios.
Surgery for Obesity and Related Diseases 01/2008; 4(1):26-32. DOI:10.1016/j.soard.2007.09.009 · 4.07 Impact Factor
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