Physical Address
304 North Cardinal St.
Dorchester Center, MA 02124
Operations for Morbid Obesity
Bariatric surgery had its beginnings in the 1950s when malabsorptive operations were performed upon patients with severe hyperlipidemia and obesity. Edward Mason was undoubtedly the father of American bariatric surgery, having first described the gastric bypass in 1969 and later the vertical banded gastroplasty (VBG) in 1981. In between, unfortunately, the field suffered a major initial setback from which it took decades to recover. The culprit was the performance of the jejunoileal bypass. The operation was originally designed for hyperlipidemia and obesity together and was frequently performed in the 1970s before its untoward side effects, especially hepatic failure in a small percentage of patients, were described and appreciated. The subsequent two decades involved reversing these operations for many of the patients who had received them, as they manifested problems with malabsorption of protein, calories, or essential minerals such as magnesium. Liver failure in 2% of patients, however, was the true insurmountable danger of this procedure.
Restriction, rather than malabsorption, was then felt to be the optimal approach for patients with morbid obesity. Various stapling operations of the stomach were performed to try to limit food intake. Many of these suffered from the lack of understanding that a staple line in an intact stomach will, in a high percentage of cases, break down and allow passage of luminal contents. This is the principle used in pyloric exclusion for duodenal injury. Thus many of the patients who had these stapling procedures experienced initial excellent weight loss but subsequent regain after the staple line broke down.
Mason then championed the VBG, which proved to have more durability than simple stapled operations. The lesser curvature of the stomach, which is resistant to dilation with pressure, was used for the restrictive pouch. The pouch outlet was reinforced with a circular piece of permanent mesh material. Due to its relative technical ease of performance, the operation became immensely popular in the 1980s and was for a period of time the most popular bariatric procedure performed. This trend continued until the last decade of the 20th century. By that time the limitations of the VBG had become apparent. Patients could not eat a normal healthy diet of vegetables and fruits, due to the restriction of the band and pouch, and turned instead to a diet of high-calorie liquids and junk food. Weight regain followed. In addition, a percentage experienced severe gastric outlet obstruction due to progressive hypertrophy around the band, requiring revisional surgery.
The operation that the VBG was revised to was most often the gastric bypass. Since its introduction in 1969, it had evolved quickly from a loop gastrojejunostomy to a Roux-en-Y gastrojejunostomy, due to complications of bile acid reflux esophagitis from the loop. Griffen et al. popularized this modification. The Roux-en-Y gastric bypass (RYGB) proved to be a very effective operation for weight loss, as well as treatment of comorbidities associated with obesity. Major proponents of the procedure during the 1980s included Sugerman, who described its efficacy in treating hypertension, diabetes, pseudotumor cerebri, and venous stasis ulcers. Pories and his group from East Carolina University were the first to emphasize the beneficial effect of RYGB on the treatment of type 2 diabetes. Improvements in life expectancy, degree of comorbid medical problems, and cost effectiveness of the procedure were soon shown in large studies by Christou and MacLean's group, Buchwald, and Adams.
Bariatric surgery experienced its only major change in operative approach, through the advent of laparoscopy, slightly later than most general surgery procedures. Wittgrove and Clark described the first laparoscopic gastric bypass in 1995. Soon thereafter, Schauer and later Nguyen and Wolfe confirmed the efficacy and benefits of performing RYGB using this approach. Patients voted rather quickly for adopting this new approach, with the incidence of RYGB in the United States increasing exponentially during the years 1999–2004 ( Fig. 63.1 ). Since then, the incidence of performance of all bariatric operations in the United States has risen only by 25% in the past 10 to 12 years. However, the spectrum of procedures and their relative safety of performance have changed significantly since the introduction of laparoscopy in the first few years of the 21st century.
The rising exponential curve of bariatric operations performed during the Bariatric Revolution.
Although the RYGB was the predominant procedure performed in the United States at the start of the 21st century, internationally the laparoscopic adjustable gastric band (LAGB), introduced by Belachew in 1994, was taking the European and Australian continents by storm. LAGB's popularity blossomed in the 15 years following its introduction, to the point where in 2009 in the United States it rivaled RYGB as the most popular operation performed for morbid obesity. Its safety profile was excellent, and it proved effective in settings where careful and available follow-up for adjustments to the band existed. Patients viewed it as a less invasive procedure, and its popularity increased accordingly. However, by 2010 the long-term efficacy of the LAGB had proven poor in many centers. Patients had experienced problems with poor weight loss, frequent prolapse of the band requiring multiple adjustments, and overall lack of satisfaction with the amount of weight loss versus the symptoms, cost, and inconvenience of maintaining the band in exactly the correct range of restriction. Centers began reporting a high incidence of band removal, with long-term follow-up showing more than 50% of bands removed in one center. Many patients lost insurance coverage for adjustments, further decreasing the efficacy of the band. By 2012 the operation was clearly on the way out, and its use has declined precipitously in the United States since then ( Table 63.1 ).
TABLE 63.1
American Society of Metabolic and Bariatric Surgery Estimate of Numbers of Bariatric Procedures in United States
| 2011 | 2012 | 2013 | 2014 | 2015 | |
|---|---|---|---|---|---|
| Total | 158,000 | 173,000 | 179,000 | 193,000 | 196,000 |
| RYGB | 36.7 | 37.5 | 34.2 | 26.8 | 23.1 |
| Sleeve | 17.8 | 33 | 42.1 | 51.7 | 53.8 |
| Band | 35.4 | 20.2 | 14 | 9.5 | 5.7 |
| DS | 0.9 | 1 | 1 | 0.4 | 0.6 |
| Revisions | 6 | 6 | 6 | 11.5 | 13.6 |
| Other | 3.2 | 2.3 | 2.7 | 0.1 | 3.2 |
DS , Duodenal switch; RYGB , Roux-en-Y gastric bypass.
Part of the reason for the LAGB decline has been the evolution of the laparoscopic sleeve gastrectomy (LSG). Initially described by Gagner and his group as being an effective first step in the two-stage performance of the laparoscopic duodenal switch (LDS) procedure, the patients who had this first stage performed experienced good weight loss and often refused to have the second stage of the duodenal switch (DS) performed. Performance of the sleeve gastrectomy as a stand-alone operation then became more popular in the years 2004–2008, and by 2009 there was considerable evidence for its efficacy. By 2011, through considerable efforts from the American Society of Metabolic and Bariatric Surgery (ASMBS), the procedure received approval as a standard operation by most insurance companies. Since then its popularity has risen to where by 2015 it had become the most commonly performed bariatric procedure in the United States (see Table 63.1 ). Patients often perceive this procedure as being less invasive, and surgeons certainly have found it to be a less technically difficult procedure than either laparoscopic RYGB (LRYGB) or LDS.
Malabsorptive procedures have never been very popular in most areas for the treatment of morbid obesity. Scopinaro and his group championed the performance of the biliopancreatic diversion (BPD) in Italy in the late 1970s and early 1980s. Its long-term efficacy in producing durable weight loss and resolution of comorbidities such as hyperlipidemia, type 2 diabetes, and hypertension has been excellent. However, it had the disadvantage of a high incidence of marginal ulcers, leading Hess and Marceau to independently and virtually simultaneously devise the DS procedure. LDS remains the internationally most commonly performed metabolic and bariatric malabsorptive operation. However, it accounts for only 2% or less of overall procedures done. Despite LDS being the best procedure for long-term weight loss, its higher incidence of significant metabolic complications, its need for more vitamin supplements, including parenteral fat-soluble vitamins, and its limitations of lifestyle, in terms of diarrhea and frequent bowel movements after eating, have limited its popularity to those patients who are in need of the most severe restriction of caloric absorption or reversal of metabolic diseases.
The safety of performance of bariatric procedures during the past 15 years has improved dramatically. In 2000 the literature reflected the fact that open RYGB had an accepted mortality rate approaching 1%, with 2% being seen in higher-risk patient populations. The profession then did an outstanding job of quality improvement through several means. Laparoscopic procedures proved less morbid, especially for long-term wound complications and incisional hernias. They also were less morbid for short-term complications, length of hospital stay, and mortality. The ASMBS and the American College of Surgeons (ACS) adopted the concept of centers of excellence, and self-review, peer pressure, and external auditing all combined to produce centers that achieved improved outcomes for bariatric procedures. By 2014 the reported national mortality rate for a LRYGB was 0.15% and even lower for LSG.
Currently, the main procedures performed in the United States and internationally are the LSG and the LRYGB. The LAGB is rapidly declining in popularity, and within a year may be as infrequently performed as LDS, which has consistently represented 1% to 2% of procedures for the past several years.
Laparoscopic Adjustable Gastric Band
The LAGB was very popular 10 to 13 years ago, and there are a large number of patients who have the device in place. Even though its popularity has decreased recently, it is still important for surgeons to understand the procedure and how it is done to be able to offer it to appropriate selected candidates, as well as treat its complications.
Patients who have had the best success with the LAGB are those whose weight loss goals do not exceed 100 pounds, who have successfully dieted in the past, and who are physically active and will remain so after the procedure. It is also quite helpful and important that patients have ongoing insurance coverage that will allow visits for adjustments of the band, as well as treatment of any complications of the band, to be covered and thus not a financial burden for the patient. Otherwise compliance and follow-up, important for the long-term success of the LAGB, will be severely compromised.
Relative contraindications to an LAGB would be a high body mass index (BMI) of more than 50, poor mobility, lack of ability to exercise, failure to have successfully dieted and lost more than 25 pounds, small hiatal hernia, and previous gastric surgery. Absolute contraindications include previous antireflux surgery, large hiatal hernias, and esophageal motility disorders.
Operative Steps
Ports for surgery are generally located above the umbilicus, within 15 to 18 cm of the xiphoid. A 15-mm and 5-mm port are placed in the right upper quadrant for the surgeon's right and left hands, respectively, with the surgeon standing on the patient's right side. The assistant, standing on the patient's left side, can optimally help with two left upper quadrant 5-mm ports. The camera port (12 mm) is placed just to the left and above the umbilicus. A liver retractor is placed in the xiphoid region ( Fig. 63.2 ).
After port placement, the surgeon opens the gastrohepatic ligament in its avascular region proximally. This pars flaccida area has been used to describe this technique of band placement. The right crus is identified, and an area approximately 2 to 3 cm below the gastroesophageal junction on the medial border of the right crus is opened with a Harmonic scalpel or similar energy device to allow the beginning of a tunnel for the lap band posterior to the stomach. This tunnel is then developed by the surgeon's left hand, gently passing a grasper from the right to left crus area posterior to the proximal stomach, hugging the surface of the crura. There is a fair amount of fibrous tissue in this area, and the goal is to develop a tunnel within this tissue that allows for some posterior security of the band, preventing migration in either direction. Once the grasper has emerged in the area of the angle of His, the band itself is introduced into the abdomen via the 15-mm port. The tubing end of the band system is then grasped by the grasper and pulled back to the patient's right crus, through the previously developed tissue tunnel. The tubing is pulled through until the band is partially around the stomach.
The band is then placed around the proximal stomach, 2 cm below the gastroesophageal junction, and with just that small amount of stomach above the top of the band. It is locked onto itself, securing it in place. The band has a locking buckle mechanism that allows it to self-secure in this location ( Fig. 63.3 ). The buckle of the band is positioned above the lesser curvature of the stomach.
The fundus is now brought up over the left lateral and anterior portions of the band to cover the band and secure it further into position. Several sutures are required to secure the fundus in this location ( Fig. 63.4 ). Care should be taken to avoid placing the fundus over the buckle of the band because erosion may occur.
The tubing is now brought out through the abdominal wall in a location where the port will be sited. We have favored placing the port just below the costal margin in the epigastric region. This location makes the port more easily palpable for adjustments. An incision is made on the abdominal wall in the desired area of the port. The tubing is brought out from the abdomen through a stab wound on the medial side of this incision, as far to the end of the incision as possible. This allows the tubing to emerge through the fascia and take a natural slow bend medially to be joined to the port. Securing the tubing to the port and then the port to the fascia in the incision site completes the operation except to visually confirm that addition of saline to the system causes the band to expand and not leak. The band is normally placed without any saline in the system to avoid initial excessive obstruction. Fig. 63.5 shows the completed LAGB.
Band Adjustments
Postoperative adjustments to the band are necessary to provide an optimal amount of restriction. When such adjustments are made, a good rule of thumb is to have the patient drink several swallows of water quickly after the adjustment is made. If the patient feels the water stop and give a sensation of partial blockage, then the adjustment is too tight and must be loosened. Optimal restriction varies from patient to patient, but in general a goal of restriction to one cup of food or less at a meal and production of satiety for at least a few hours after eating are the goals of an optimal adjustment.
Probably more so than any of the other procedures, the success of LAGB is dependent on patient understanding of diet recommendations and compliance. The LAGB should help promote healthy eating habits, and nutritional counseling on a frequent basis, especially early after the procedure, is important.
Outcomes
The LAGB has produced some excellent initial results in patients. O'Brien and colleagues probably had the best overall international experience with the band. Ren and Fielding published a large experience with good results in the United States. Optimal weight loss at 3 years after LAGB was approximately 50% of excess weight in these series. Dixon et al. showed the efficacy of the LAGB in treating type 2 diabetes. Long-term results have been less overall good and more controversial. There are published reports of a high incidence of band removal after 10 years. A combination of patient frustration with the lack of progressive weight loss with the band, recurrent prolapse or other adjustment issues, and the need for ongoing readjustments have caused an increasing number of patients to seek band removal with or without a second bariatric operation. More attractive outcomes from sleeve gastrectomy have caused most surgeons to drastically decrease placement of the LAGB in favor of other procedures such as the sleeve gastrectomy.
Complications
Early postoperative complications after band placement are rare, and discharge the same day is the norm. However, complications can occur, and these have been well described in the literature. Inaccurate or poor dissection technique can result in gastric perforation and postoperative leak. Early band erosion occurs in approximately 1% or less of cases.
Stenosis at the band site, or excessive band restriction, will produce nausea and vomiting in most situations but can also present as new-onset gastroesophageal reflux disease (GERD) in less stenotic situations. Any such symptoms of new onset need to be investigated promptly for either simple excessive restriction or, more commonly, prolapse of the band. Prolapse occurs when the stomach below the band herniates up into the central lumen of the band and too much stomach is forced into this space. Complete or partial obstruction results. In severe cases the prolapse can lead to ischemia and gangrene of the prolapsed portion of the stomach. Chronic prolapse is seen at times with surprisingly large protrusions of the distal stomach up and over the edge of the gastric band. Technically prolapse is when the stomach herniates up through the band. Slippage is when the band slips down onto the stomach. Both produce the same end result mechanically and symptomatically. Prolapse can occur at any time after the procedure, and its incidence slowly rises with duration of the band being in place. Recurrent prolapse has been a common reason for band removal among patients.
Diagnosis of prolapse is a clinical and, if necessary, radiographic one. The signs and symptoms are of obstruction or GERD, with obstruction present in most cases. A plain film of the abdomen will reveal the band position, normally at a 7 o'clock to 1 o'clock orientation, flattened to horizontal on the film. This is diagnostic for prolapse. If doubt exists, a low-volume Gastrografin or barium swallow will confirm the diagnosis.
Treatment for prolapse initially is removal of all fluid in the system. This will, in most cases of acute prolapse, provide enough reduction in the restriction of the prolapsed stomach to allow it to slip back down through the band and resume its normal position. However, if removal of all fluid does not produce immediate relief of symptoms by the patient, a swallow study is indicated. If the swallow shows a large and persistent prolapse, emergent surgical therapy is indicated to laparoscopically reduce the prolapse and prevent gastric ischemia. A laparoscopic approach to freeing the buckle of the band, unbuckling the system, reducing the prolapse to its appropriate location, and repositioning and rebuckling the band is quite feasible.
Other complications are less common. Chronic stenosis or band placement too high onto the distal esophagus may produce esophageal obstruction and dilation. This must be corrected when diagnosed. Resolution of the obstruction will usually result in the esophagus regaining its normal size. Failure to secure the port to the fascia can result in the port turning in the subcutaneous space and being unable to be accessed for further adjustments. An outpatient procedure under local anesthesia can correct this problem.
Laparoscopic Roux-en-Y Gastric Bypass
The gold standard operation for bariatric surgery has been the RYGB. It achieved initial popularity in the mid 1970s and has remained a standard operation since that time. The operation was first described by Mason and Itoh in 1969. Griffen published the first large experience after revising it to a Roux limb. It stood the test of time as the VBG came and went in the 1980s and 1990s. As described previously, Wittgrove's description of its performance laparoscopically and Schauer and others' reports soon championed the laparoscopic approach. LRYGB was the most common procedure performed in the early part of the 21st century, when bariatric centers of excellence were formulated and when greater attention to quality outcomes produced significant improvements in the safety of the procedure.
As with many popular operations, there are considerable variations on the theme as to how to best perform LRYGB. The technique of creating the gastrojejunostomy and the length and location of the Roux limb has varied from surgeon to surgeon. No optimal technique or configuration has emerged, although some differences have been shown. Its performance using a laparoscopic approach has clearly been an improvement over the open approach, as with all other operations where minimal access has been used. Elimination of incisional hernias, decreased pain and recovery time, and decreased overall complication rates and mortality have all been confirmed with using the laparoscopic approach.
Indications for performing LRYGB follow the general guidelines for metabolic and bariatric surgery as outlined in the National Institutes of Health (NIH) Consensus conference of 1990. A BMI greater than 40 or greater than 35 with comorbid medical problems associated with obesity are the indications. Failure of a trial of dieting and mental stability are also considered standard criteria. Other criteria vary among surgeons and institutions, including upper and lower age limits, size limits, and requirements of cessation of addictive habits. Patients who have significant symptoms from GERD or who have insulin-dependent type 2 diabetes remain optimal candidates for LRYGB in our practice. LRYGB has been shown to give superior results in treating GERD and insulin-dependent diabetes. Another factor that favors LRYGB over other operations is its known durability (when considering the younger patient). It also produces the overall best weight loss and resolution of comorbid medical problems of all the restrictive operations, although sleeve gastrectomy has been shown to have close to comparable results in some studies in which GERD and type 2 diabetes are not factors.
Absolute contraindications to LRYGB include failure to meet NIH criteria, psychiatric instability, ongoing drug or alcohol addiction, and excessively morbid medical problems precluding safe surgery. Relative contraindications include age younger than 15 or older than 65 to 70, weight greater than 600 pounds (our cutoff), persistent smoking, lack of mobility, and severe medical problems.
Operative Steps
We use a similar port placement for LRYGB as we do for LAGB. Many surgeons do not use as many ports for LAGB. However, for LRYGB, we find the assistant having two available hands to assist is very helpful to essential in many steps of the operation. The superior left upper quadrant port is a 12-mm one in this procedure as we perform it, because we do a double-stapled enteroenterostomy technique and the stapler angle is optimal from that location for the second firing ( Fig. 63.6 ).
After ports are placed, I prefer to create the Roux limb as the first step. The ligament of Treitz is clearly identified, after which the proximal jejunum is divided with a white load of the GIA stapler (Covidien-Medtronic, Dublin, Ireland) at approximately 45 to 50 cm distal to the ligament ( Fig. 63.7 ). The mesentery is then further divided with the Harmonic scalpel to obtain as deep a division of the mesentery as possible without encountering the very large vessels at the base of the mesentery. The proximal end of the Roux limb is then marked by suturing a small Penrose drain to it. The Roux limb length is now estimated and measured. I usually prefer a 150-cm Roux limb for patients with a BMI greater than 50. As the limb is being measured, it is pulled to the left upper quadrant. The jejunum at the desired distance is then placed adjacent to the proximal jejunum, with the distal end of the proximal jejunum facing to the patient's right and the proximal end of the Roux limb with the Penrose on it facing up and to the left. A double-stapled enteroenterostomy is now created with two white loads of the GIA stapler. The stapler defect is sewn closed with running absorbable suture. Then the mesenteric defect at the enteroenterostomy is closed with a running permanent suture.
The transverse colon mesentery is now grasped and elevated, exposing the lower portion of the mesentery near the ligament of Treitz. A defect is made in the mesentery to the left and a few centimeters above the ligament of Treitz. This location usually avoids major vessels, but the surgeon must be aware of the vascular anatomy, if visible, and cautious not to disrupt it unnecessarily. Openings between mesenteric vessels are easier to find than dealing with bleeding from major mesenteric vessels. Once the mesentery has been opened to expose the lesser sac, the posterior surface of the stomach can be seen. It is grasped and pulled out of the mesenteric defect a few centimeters, after which the plane below the stomach is confirmed with a grasper. Adhesions, if present, are divided to now allow the Penrose drain and then the proximal end of the Roux limb to be placed into the retrogastric space ( Fig. 63.8 ). Usually if one can pass 4 cm of bowel or more past the cut edge of the mesentery, that will suffice for later retrieval. Perhaps one of the most important technical issues now must be strictly obeyed. The Roux limb mesentery must not have any twists in it. It is very easy to have the bowel twisted a full 180 degrees or more between first passing it to the left upper quadrant then retrieving it to pass it through the transverse colon mesentery. The mesentery of the Roux limb must be visually confirmed without a doubt as being straight and vertical as the limb is passed superiorly through the transverse colon mesentery.
Now attention is shifted to the stomach. The left lobe of the liver is retracted with a laparoscopic liver retractor of the surgeon's choice. The Harmonic scalpel is used to create an opening in the mesentery along the lesser curvature of the stomach. For most patients, this can be done a centimeter or two above the incisura. However, for very large patients, creating this opening at the incisura is advisable because the longer gastric pouch is often needed to allow the Roux limb to easily reach the proximal stomach without tension. Once the opening is created, a green load of the GIA stapler is fired from the lesser curvature of the stomach to partially divide the stomach body. Then I prefer to size the pouch with an Ewald tube (30 French) and place the stapler close to but not directly adjacent to the tube, which is visible by the contour it creates on the gastric surface. The stapler, now firing directly cephalad parallel to the lesser curvature, is fired several times until the stomach is divided up to the angle of His ( Fig. 63.9 ). It is important to exclude the fundus from the proximal part of the newly created gastric pouch. Care should be taken not to catch the Penrose drain in the stapler. Similarly, the anesthesiologist needs to double confirm there are no temperature probes or orogastric tubes in the stomach other than the Ewald tube.
The Penrose drain is now usually visible in the retrogastric space. If it is not, the inferior surface of the transverse colon mesentery must again be exposed and the Roux limb passed into the retrogastric space again. I continue to use a retrogastric retrocolic location of the Roux limb due to the fact this is the shortest distance from between jejunum and proximal stomach. A more popular approach is to bring the Roux limb directly anterior to both transverse colon and distal stomach and create the gastrojejunostomy. This approach is technically easier, except when the mesentery of the Roux limb is short and there is difficulty in stretching the Roux limb to reach the proximal gastric pouch. For the retrocolic retrogastric approach, I now place the proximal suture line of the Roux limb directly adjacent to the distal part of the proximal gastric pouch. The distal 5 cm of gastric pouch is then tacked to the side of the proximal 5 cm of the Roux limb with a running absorbable suture.
The gastrojejunostomy is created using a linear stapling device. We have found that the linear stapler is associated with an insignificant incidence of postoperative stenosis, whereas the circular stapler in our experience yielded a 10% or higher stenosis rate. The Ewald tube serves as a good backstop against which to make a gastrotomy in the end of the pouch. An enterotomy in the Roux limb is less difficult. Having pulled the Ewald tube back, the stapler is advanced into the two lumens to its full extent and fired ( Fig. 63.10 ). We have not found that restricting the anastomotic size has any relationship to long-term postoperative weight loss. The gastric pouch size must be small, but the anastomosis need not be very small. The staple defect is closed with a running layer of absorbable suture and reinforced with a second such layer. An intraoperative leak test is now performed by having the anesthesiologist forcefully inject a methylene blue dye solution into the lumen of the proximal pouch, after having readvanced the tip of the Ewald tube to that level.
Closure of the mesenteric defects with permanent suture is now performed. For this procedure, the Roux limb must be secured to the jejunum at the ligament of Treitz to prevent the Roux limb from telescoping up into the retrogastric space and becoming kinked and obstructed. I use a short four-bite purse-string suture between those two loops of bowel at the ligament of Treitz area and two bites of the transverse colon mesentery above the pieces of bowel ( Fig. 63.11 ). Further sutures between the two limbs are placed, as well as sutures to close the space between the left lateral side of the Roux limb and the transverse colon mesentery. Fig. 63.12 shows the completed LRYGB.
Port sites 12 mm or larger are closed with laparoscopically passed sutures for the fascia. I do not routinely use drains or nasogastric tubes after this operation.
Postoperative care includes providing adequate analgesia, early ambulation, liquids on postoperative day 1, and discharge on postoperative day 2 on our phase 2 gastric bypass diet (blenderized food). A Foley catheter is used and removed on the first postoperative day. This may be unnecessary. I still perform a Gastrografin swallow on the first postoperative day to confirm no distal obstruction, as well as no obvious leak.
Outcomes
LRYGB is associated with excellent weight loss and resolution of comorbid medical problems. We have recently published our 10-year outcomes for patients undergoing RYGB. Some of these patients had an open procedure, but most had a laparoscopic one. At 10 years the overall excess BMI loss was 52%. There was a significant improvement in obesity-related comorbid medical problems for all problems assessed after 10 years. This was true even in patients who had regained weight after initial weight loss. Excess BMI loss was maximal at approximately 70% for the first 3 years after surgery but by year 5 had decreased to closer to approximately 65%. Type 2 diabetes remained in remission in 60% of patients, hypertension in 45%, and obstructive sleep apnea in 65%. Data from national databases show that the incidence of mortality in recent years after LRYGB is now 0.14%, with complication rates being in the 5.9% range at 30 days.
Complications
You're Reading a Preview
Become a Clinical Tree membership for Full access and enjoy Unlimited articles
If you are a member. Log in here