Acute preoperative weight loss: Does it improve ease of laparoscopic gastric bypass?

292

Abstracts: Students/Residents/Fellows Session/Surgery for Obesity and Related Diseases / 1 (2005) 291–294

Methods: The medical records of patients ⬍20 years of age who underwent LRYGBP for morbid obesity from 1999 to the present were reviewed. Outcome variables examined included preoperative body mass index (BMI); percentage of excess weight lost for those with at least 3 months’ follow-up; and the reduction of comorbid conditions. Data are presented as the mean ⫾ SEM. Results: Nineteen patients (13 females, 6 males) met National Institute of Health criteria for bariatric surgery. All procedures were completed laparoscopically. Mean time to follow-up was 9.3 ⫾ 2.39 months (range 1–36). Average age was 18 ⫾ 0.4 years, and average BMI was 52 ⫾ 1.78 kg/m2. The percentage of excess weight lost for patients with follow-up of ⱖ3 months was 53.4 ⫾ 5.41%. The average number of comorbidities was 4.5, with improvement of 56% of comorbidities in 12 patients and resolution of 38% in 10 patients. There were no mortalities. There were 3 complications: postoperative bleeding in 1 patient, and marginal ulcer in 2 patients. Surveys obtained from 13 patients reflected an overall perceived improvement in quality of life. Conclusions: Laparoscopic gastric bypass is an effective option for morbidly obese adolescents. Methods by which to maximize compliance in this population must be explored. PII: S1550-7289(05)00318-7

SRF4.

IS LAPAROSCOPIC GASTRIC BYPASS SURGERY SAFE IN THE ELDERLY? John Paul Gonzalvo, D.O., Priscila Antozzi, M.D., Richard Gordon, M.D., Conrad H. Simpfendorfer, M.D., Flavia Soto, M.D., Oliver Whipple, M.D., Samuel Szomstein, M.D., Raul Rosenthal, M.D., The Bariatric Institute, Cleveland Clinic Florida, Weston, FL. Purpose: As the American public age at an increasing rate and the problem of obesity escalates, age as an absolute contraindication to bariatric surgery is being challenged. The aim of our study was to examine the safety and weight reduction for patients ⬎60 years of age who underwent laparoscopic Roux-en-Y gastric bypass. Methods: The prospectively collected database was queried for patients ⬎60 years of age. Age, gender, preoperative weight, preoperative body mass index, postoperative weight, postoperative BMI, early complications, and late complications were then assessed. Results: From 1200 patients who had laparoscopic gastric bypass, 93 were ⬎60 years old, including 59 women (63%) and 34 men (37%), with an average age of 62.2 years (range 60 –74). The average preoperative weight and BMI were 300.6 lb and 48.54 kg/m2, respectively. The 12-month postoperative average weight and BMI was 237.9 lb and 38.4 kg/m2, respectively. A total of 55 patients had follow-up in our clinic. Early complications included anastomotic leak in 3 patients (3.2%), intraluminal bleeding in 1 (1.1%), pulmonary embolus in 1 (1.1%), pneumonia in 1 (1.1%), and atrial fibrillation in 1 (1.1%). Late complications were stenosis in 8 patients (8.6%), marginal ulcer in 3 (3.2%), hernia in 2 (2.2%), and small bowel obstruction in 1 (1.1%). There were no deaths. Conclusions: Laparoscopic gastric bypass can be safely performed in patients ⬎60 years old with no mortality and low morbidity. Chronologic age should not be a contraindication to laparoscopic gastric bypass surgery. PII: S1550-7289(05)00319-9

SRF5.

GLYCEMIC CONTROL IN MORBIDLY OBESE RURAL POPULATION AFTER ROUX-EN-Y GASTRIC BYPASS Salman Malik, M.D., Marc Rogers, M.D., Vittorio Lombardo, M.D., Parkash Paragi, M.D., Craig Woods, M.D., Christopher Still, D.O., Anthony Petrick, M.D., Geisinger Medical Center, Danville, PA. Purpose: Roux-en-Y gastric bypass (RYGB) has demonstrated improved glycemic control in studies done at urban medical centers. The aim of this study was to examine the effect of RYGB on glycemic control in morbidly obese patients with type 2 diabetes (DM-TII) in a rural medical center. Methods: Data were collected from 124 patients in from rural counties who underwent RYGB between 2001 and 2003. Patients with DM-TII, HbA1c 6, and BMI ⬎40 and who completed a 6-month evaluation in a comprehensive obesity clinic, were considered for RYGB. The pre- and postoperative HbA1c measurements, body mass index (BMI), percentage of excess body weight loss (%EWL), and number of antidiabetic medications were retrospectively analyzed. Data were examined using repeated measures mixed regression models to determine whether age, gender, or procedure type (laparoscopic RYGB vs. open RYGB) predicted for weight loss or glycemic control. Results: Pre-Op 2

⫺7.8* [7.2–8.3] 24.9* [12.0–37.8] 7.8 (SD⫽1.5) ⫺1.6* [1.3–1.9] 78.3% 24.2%* [16.2%–33.9%]

BMI (kg/m ) 50 (SD⫽7) EBWL (%) HbA1c (%) Anti–DM meds (%)

3-months [95% CI]

NA

6-months [95% CI]

12-months [95% CI]

Last follow-up [95% CI]

⫺11.7* [10.9–12.5] 38.2* [25.3–51.2] ⫺1.7* [1.4–2.1] 15.5%* [8.5%–25.0%]

⫺14.6* [13.5–15.7] 48.3* [35.2–61.4] ⫺1.8* [1.5–2.2] 6.4%* [1.8%–15.5%]

⫺14.8* [13.6–16.1] 53.8* [39.4–68.3] ⫺1.4* [1.0–1.9] 6.4%* [1.8%–15.5%]

* p-value ⬍ 0.001 as compared to pre-op

Conclusions: Rural DM-TII patient populations experienced similar weight loss and improved glycemic control after RYGB as urban populations. Patients also had a significantly reduced requirement for diabetic medications. This effect was durable up to mean of 18 months after surgery and validates earlier findings in urban medical centers. PII: S1550-7289(05)00320-5

SRF6.

ACUTE PREOPERATIVE WEIGHT LOSS: DOES IT IMPROVE EASE OF LAPAROSCOPIC GASTRIC BYPASS? Rockson C. Liu, M.D., Adheesh Sabnis, M.D., Bipan Chand, M.D., The Cleveland Clinic Foundation Department of General Surgery, Cleveland, OH. Purpose: Prohibitive liver size and massive intraabdominal adiposity result in poor visualization and complications in gastric bypass. We hypothesize that acute preoperative weight loss can reduce liver size and improve visualization, thereby facilitating the creation of the gastric pouch and gastrojejunostomy. Methods: Consecutive patients were included in this retrospective study if they had had no prior bariatric surgery and had undergone isolated laparoscopic Roux-en-Y gastric bypass (by a single surgeon) between July 2003 and September 2004. All patients par-

Abstracts: Students/Residents/Fellows Session/Surgery for Obesity and Related Diseases / 1 (2005) 291–294

ticipated in our institution’s medically supervised weight management program before surgery. Results: Preoperatively, 30 patients (Group A) lost an average of 4% excess body weight (EBW) and 43 patients (Group B) did not lose weight or gained an average of 6% EBW over an average period of 3.3 months. There were no differences between the two groups in starting BMI, number of comorbidities, or the last preoperative BMI. Group A had less intraoperative blood loss (106 vs. 72 mL, p ⫽ 0.01). No differences were seen between Group A and Group B with respect to operative times (180 vs. 179 min, p ⫽ NS), intraoperative complications/conversions (3.3% vs. 14%, p ⫽ 0.2), need for additional trocars (6.7% vs. 4.7%, p ⫽ NS), or anastamotic leaks/obstructions (3.3% vs. 7%, p ⫽ NS). Conclusions: Minimal acute preoperative weight loss is associated with less blood loss and appears to reduce intraoperative complications and conversions in laparoscopic gastric bypass. A larger series with a greater reduction in EBW is necessary determine the maximal benefits of acute preoperative weight loss. PII: S1550-7289(05)00321-7

SRF7.

IS GALLBLADDER ULTRASOUND NECESSARY IN PATIENTS UNDERGOING LAPAROSCOPIC ROUX-ENY GASTRIC BYPASS? Federico A. Ceppa, M.D., Pavlos K. Papasavas, M.D., Daniel J. Gagne´, M.D., Cornelia Savopoulou, M.D., Philip F. Caushaj, M.D., Temple University Clinical Campus at the Western Pennsylvania Hospital, Pittsburgh, PA. Purpose: Bariatric surgeons perform either routine cholecystectomy at the time of laparoscopic Roux-en-Y gastric bypass (LRYGBP), selectively in patients with positive ultrasound (US) or not at all. We reviewed our experience with biliary disease in patients undergoing LRYGBP. Methods: From July 1999 to October 2004, 647 patients underwent LRYGBP in our institution. Data on preoperative US were available in 557 patients. Preoperative US was routinely obtained early in our series and selectively thereafter in patients with suspected symptomatic biliary disease. Cholecystectomy, at the time of LRYGBP, was performed in symptomatic patients with positive US. Results: Three of 21 patients with no preoperative US presented with common bile duct pathology that was treated with laparoscopic transgastric ERCP and sphincterotomy (n ⫽ 2) or common bile duct exploration (n ⫽ 1). GROUPS

NUMBER Lap Chole Lap Chole Lap Chole % Lap Chole Mean prior to with After after follow-up LRYGBP LRYGBP LYRGBP LYRGBP (months)

Preop Chole US Positive Symptomatic US Positive Asymptomatic US Negative Asymptomatic No Preop US TOTAL

133 18

133 0

0 18

0 0

0% 0%

15

0

0

1

6.6%

10.7

64

0

0

3

4.7%

15.1

6.4%

10.5

327 557

0 133(24%)

0 18(3.2%)

21 25(4.5%)

Conclusions: Omission of preoperative US is associated with an acceptable rate of postoperative biliary disease, which can be treated laparoscopically safely. PII: S1550-7289(05)00322-9

293

SRF8.

SELECTIVE LAPAROSCOPIC CHOLECYSTECTOMY DURING LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS Alexander Perez, M.D., Lauren Seymour, P.A.-C., Jay Kuhn, M.D., Imtiaz A. Munshi, M.D., Department of Surgery, Baystate Medical Center, Tufts University School of Medicine, Springfield, MA. Purpose: It has been proposed that laparoscopic cholecystectomy (LC) be done routinely during laparoscopic Roux-en-Y gastric bypass (LRGB). It is believed there is a high incidence of gallbladder disease despite negative clinical or radiographic preoperative findings. However, it has been shown that gallbladder removal prolongs operative times as well as the hospital length of stay. We performed an interim analysis of our experience to evaluate these concepts. Methods: Retrospective review of prospective data over 1 year, on all consecutive LRGB and LRGB/LC cases performed by the same surgeon using the same technique. Patients with clinical or radiographic evidence biliary disease and/or intraoperative finding of inflammation had LC after LRGB. Pathologic findings were reviewed after each case. Statistics used include Student’s t test and chi-square test. Data are expressed as mean ⫾ SD. Results: One patient required conversion of LC to open cholecystectomy due to the inability to define the anatomy adequately. One asymptomatic patient with ultrasonographic evidence of cholelithiasis was found to have a pT2 adenocarcinoma. Conclusions: While our data cannot support routine LC with LRGB, a select subset of patients can have LC performed safely without increasing the hospital length of stay, but this does increase the OR time. PII: S1550-7289(05)00323-0

SRF9.

BANDS VERSUS BYPASSES: RANDOMIZATION AND PATIENTS’ CHOICES AND PERCEPTIONS Craig A. Ternovits, M.D., David S. Tichansky, M.D., Atul K. Madan, M.D., University of Tennessee Health Science Center, Memphis, TN. Purpose: The laparoscopic gastric bypass and laparoscopic adjustable gastric band have become two increasingly popular procedures. Little is understood about patient motivational factors and reasons for procedure selection. This investigation explored patient choices and perceptions concerning laparoscopic gastric bypass and laparoscopic adjustable banding. Methods: A survey was given to patients who had undergone laparoscopic gastric bypass and laparoscopic adjustable gastric banding. The survey was designed to ascertain what reasons the patients relied on to choose banding versus bypass, as well as their perception on how they had done from their surgery. Results: There were 101 patients who filled out the survey. 22 patients had undergone laparoscopic placement of the adjustable band, and 79 for the laparoscopic gastric bypass. Overall, 21% of patients would be willing to be involved in a prospective randomized study with respect to bariatric procedure choice. While 6 of 22 (32%) band patients stated that they would be willing to undergo randomization of their bariatric procedure, only 12 of 79 (18%) bypass patients would be willing to be randomized.