Complications of laparoscopic Roux en-Y gastric bypass

10. Scopinaro N, Gianetta E, Friedman D, et al. Evolution of

biliopancreatic bypass. Clin Nutri. 1985;5(suppl):137-146. 11. Marceau P, Biron S, Bourgue RA, et al. Biliopancreatic

diversion with a new type of gastrectomy. Obes Surg. 1993;3:29-35.

to be the preferred technique to minimize this complication, which may result in weight regain and occurrence of the intractable marginal ulceration, the technique of superimposed 3 rows of staples described by Sugerman,1 decreases this complication to less than 2%. We utilize this technique in the open gastric bypass and share similar observation.

12. Sugerman HJ, Brewer WH, Shiffman ML, et al. Prophy-

PIOTR GORECKI, MD LESLIE WISE, MD Division of Laparoscopic Surgery Department of Surgery New York Methodist Hospital Brooklyn, New York

lactic Ursodiol acid prevents gallstone formation following gastric bypass induced rapid weight loss: a multicenter placebo controlled, randomized double-blind prospective trial. Am J Surg. 1994;169:91-96. 13. MacLean LD, Rhode BM, Forse RA. Late results of verti-

cal banded gastroplasty for morbid and super obesity. Surgery. 1990;107:20-27. 14. Sugerman HJ, Kellum JM, Engle KM. Gastric bypass for

treating severe obesity. Am J Clin Nutri. 1992;55:560s-566s. 15. Cucchi SG, Pories WJ, MacDonald KG, et al. Gastroga-

stric fistulas. A complication of divided gastric surgery. Ann Surg. 1995;221:387-391. 16. Sapla JA, Wood MH, Sapala MA, Flake TM Jr. Marginal

ulcer after gastric bypass: a prospective 3-year study of 173 patients. Obes Surg. 1998;8:505-516. 17. Sugerman HJ, Kellum JM, DeMaria EJ. Conversion of

proximal to distal gastric bypass for failed gastric bypass for superobesity. J Gastrointest Surg. 1997;1:517-525. 18. Behrns KE, Smith CD, Sarr MG. Prospective evaluation

of gastric acid secretion and cobalamine absorption following gastric bypass for clinically severe obesity. Dig Dis Sci. 1994;39:315-320. 19. Brolin RE, Gorman JH, Gorman RC, et al. Prophylactic

iron supplementation after Roux-en-Y gastric bypass: a prospective, double-blind, randomized study. Arch Surg. 1998;133:740-744. 20. Mallory GN, MacGregor AMC. Folate status following

gastric bypass surgery (The Great Folate Mystery). Obes Surg. 1991;1:69-72. 21. Brolin RE, Gorman JH, Gorman RC, et al. Are vitamin

B-12 and folate deficiency clinically important after Rouxen-Y gastric bypass? J Gastrointest Surg. 1998;2:436-442. 22. Brolin RE, LaMarca LB, Kenler HA, Cody RP. Malab-

sorptive gastric bypass in patients with superobesity. J Gastrointest Surg. 2002;6:195-205.

EDITORIAL COMMENTS Dr Brolin’s list of general and specific complications of RYGB is very descriptive. We would like to add to the controversy of the gastrogastric fistula following stapled or divided gastric bypass. As Dr Brolin points out, although divided gastric bypass seems 142

REFERENCE 1. Sugerman HJ, Kellum JM, Engle KM, et al. Gastric bypass

for treating severe obesity. Am J Clin Nutr. 1992; 55(suppl):560-566.

COMPLICATIONS OF LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS The laparoscopic Roux-en-Y gastric bypass (LRYGB) has all the traditional complications of open gastric bypass and the general complications of a minimally invasive approach, both of which have been previously discussed in this symposium, and will not be repeated in this paper in the interest of brevity. Please refer to the sections by Brolin on open gastric bypass, and my discussion of complications of laparoscopic VBG for a comprehensive review of issues of surgeon training, patient selection, and trocar problems, which can occur with laparoscopic bariatric surgery. The unique problems presented by the LRYGB include complications of calibration and construction, technical issues of stoma formation (gastro-jejunostomy and entero-enterostomy) and postoperative stenosis, and techniques to reduce small bowel obstruction. The challenge with adoption of a minimally invasive approach of an established procedure is to perform the same operation without compromising technique for laparoscopic access. The open gastric bypass long-term success depends on a measured and calibrated pouch of less than 30 cc, a stoma outlet of 12 mm, and a Roux limb of 100 cm. Many laparoscopic bariatric surgeons unnecessarily “eyeball” pouch construction, outlet diameter, and Roux limb length with no method of calibration.1,2 The pouch should be calibrated with a balloon or bougie, the outlet with a bougie, gastroscope or circular stapler anvil, and the Roux limb accurately measured with an endoscopic ruler.3 The distortion of lens magnification and lack of depth perception and tactile sensation associated with laparoscopic surgery is a setup for technical failures and revisions unless addressed at the initial procedure. The primary design of the Roux-en-Y gastric bypass may also be modified or compromised in order to simplify the procedure for laparoscopy, such as the resurrected “loop gastric bypass.”4 CURRENT SURGERY • Volume 60/Number 2 • March/April 2003

This procedure avoids creation of the entero-enterostomy, thereby simplifying and speeding the surgery, while ignoring the bile reflux and history of disastrous outcomes with the open approach in the past. Avoid complications by adopting proven and endorsed techniques that have been endorsed by the NIH or national surgical societies.5,6 The technique of formation of the gastro-jejunostomy required modification for laparoscopy, and it has spawned a new set of complications. The current 3 common techniques are the circular stapler, linear stapler, or hand sewn anastamosis.1-3,7 The circular stapler if passed transorally has been reported to become lodged in the esophagus or to cause esophageal lacerations. Passing the anvil per oral and withdrawing the stapler through the abdominal wall has resulted in a definite incidence of wound infections, and the enlarged 2-cm incision is more prone to incisional hernias.1,2 A modification to avoid the transoral route infection risk was to insert the anvil via a gastrostomy, which we employed in 1995 and was later popularized by Scott and Dela Torre.8 This still required a 2-cm incision to insert the 21-mm stapler shaft, which was difficult to close accurately in patients with morbid obesity. Our solution was to develop the linear stapler technique, so the stapler could be inserted via a standard 12-mm trocar.3 With this approach, we have experienced only 2 wound infections, 1 incisional trocar hernia, and 1 anastomotic leak in 985 laparoscopic gastric bypasses over a 7-year period. Higa and Boone7 employ a handsewn anastomosis to avoid the technical issues of laparoscopic stapling and were thought initially to reduce leak rates. Leaks still occur with the hand-sewn approach, however, and the challenge of a running suture line is beyond all but a handfull of endoscopic bariatric surgeons, so its utilization has been limited. In our opinion, there is no significant difference in leak rates among the 3 principal techniques, and it is most dependent on the surgeon’s skill and training. The learning curve for laparoscopic gastric bypass is generally accepted as being at least 100 cases.2,7 Leaks may be more common with a laparoscopic gastric bypass, particularly early in the learning curve; therefore, we strongly urge laparoscopic surgeons to assess for leaks at the end of the case before closing. Leaks may be tested by flooding the field with saline to cover the staple and suture lines and instilling air via a gastroscope, or by instilling methylene blue via a nasogastric tube with a bowel clamp occluding the Roux limb. We identified 31 intraoperative leaks in our first 825 laparoscopic gastric bypasses, but had only 1 (0.12%) leak postoperatively from the gastro-jejunostomy.9 It is a good policy to utilize a drain in your first 100 cases until you establish a known leak rate. A postoperative gastrografin swallow is also recommended during the learning curve to assess for missed leaks. Remember, however, that a negative gastrografin swallow does not rule out a leak at the gastro-jejunostomy, or at the other multiple sites where leaks occur (entero-enterostomy, distal stomach staple lines, or iatrogenic injury at remote sites). There was early speculation that the incidence of stoma stenosis would be increased with a laparoscopic approach, but the rate has been reported as 0% to 10%, with an average of 5% to CURRENT SURGERY • Volume 60/Number 2 • March/April 2003

8% in our experience.10 There are three issues to consider in comparing stenosis rates: (1) how aggressive the primary surgeon is in investigating patient complaints, (2) if the surgeon performs his own endoscopy, and (3) how is a stenosis defined. We investigate any patient who cannot advance to solids by 6 weeks after extensive diet counseling. A barium swallow is a poor test unless it demonstrates a significant stenosis, due to a high incidence of false-negatives. A gastroscopy is the definitive test, and it gives the examiner an opportunity to perform a balloon dilation of the gastro-jejunostomy. We perform our own endoscopy and define a stenosis as any outlet through which we cannot pass our 10-mm gastroscope. We average a 6% stenosis rate postoperatively and have successfully dilated each stenosis without a revision; however, we have had 2 (3.6%) perforations requiring surgical repair from dilation associated with a 18-mm balloon. We recommend not dilating above a 15-mm balloon based on our outcomes. We have dilated patients from 1 to 4 times, but over 90% require only 1 treatment. The final topic to address is the incidence and etiology of small bowel obstruction after laparoscopic gastric bypass. Initially we believed that the incidence might be lower than with open surgery, due to less scarring. What has been observed by a number of authors is an increased incidence of internal hernias at the mesocolon window, Petersen’s space, and the enteroenterostomy mesenteric defect due to a lack of scarring compared to open surgery.11-13 It is recommended that the defects be meticulously closed with running permanent suture to decrease this risk. Absorbable suture or interrupted closure does not appear as effective.13 Closure does not guarantee resolution, however, and we are now seeing a definite occurrence of internal hernias at 3 to 4 years postoperative after significant weight loss. The other current debate to reduce the incidence of postoperative obstructions centers on where to place the Roux limb, either retrocolic or antecolic. The argument centers on the undocumented opinion that the retrocolic route represents a shorter distance to the pouch and thereby will create less tension, less leaks, and less stenosis. In fact, there are no data in the laparoscopic bariatric surgery literature to support this perception. The retrocolic route creates a defect in the mesocolon that is a significant source of internal hernias. Two recent retrospective series that compared the retrocolic versus antecolic approach found a significant decrease in the incidence of postoperative small bowel obstruction in the antecolic cohort.11,12 There was no increased incidence of leaks or stenosis in our antecolic group when we analyzed this outcome. Although these data are retrospective and nonrandomized, it does represent outcomes in 1447 patients over a 7-year period by 2 separate and independent groups, although there is no series to report the superiority of a retrocolic approach. There has been a recent explosion of interest in laparoscopic bariatric surgery by patients and surgeons due to the marked decrease in wound morbidity and reduced hospital stay and overall recovery. This resurgence will come to an abrupt halt if complications increase due to poor surgeon outcomes second143

ary to inadequate training and preparation. It is imperative that surgeons contemplating laparoscopic bariatric surgery become proficient in advanced laparoscopic surgery and bariatric surgery. J. K. CHAMPION, MD Mercer University School of Medicine Atlanta, Georgia

REFERENCES 1. Wittgrove AC, Clark GW. Laparoscopic gastric bypass,

Roux-en-Y-500 patients: technique and results, with 3-60 month followup. Obes Surg. 2000;10:233-239. 2. Schauer PR, Ikramuddin S, Gourash W, Ramanathan R,

Luketich J. Outcomes after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Ann Surg. 2000;4:515-529. 3. Champion JK, Hunt T, DeLisle N. Laparoscopic vertical

banded gastroplasty and Roux-en-Y gastric bypass. Obes Surg. 1999;9:123. 4. Rutledge R. The mini-gastric bypass: experience with the

first 1274 cases. Obes Surg. 2001;11:276-280. 5. Guidelines for laparoscopic and open surgical treatment of

morbid obesity. ASBS and SAGES joint statement. Obes Surg 2000;10:378-379. 6. Gastrointestinal surgery for severe obesity: NIH consensus

development conference March 25-27, 1991. Am J Clin Nutr. 1992;55:615S-619S.

EDITORIAL COMMENTS In a prospective, randomized trial, laparoscopic Roux-en-Y gastric bypass has been shown to be a safe and cost-effective alternative to open RYGB.1 In the review of complications specific to this operation, Dr. Champion illustrated his current preferred technique of the laparoscopic procedure, which eliminated the need for transoral placement of the anvil of the circular stapler and eliminated the need for creation of the mesocolic defect for passage of the Roux limb. Both eliminated steps were previously reported to be a source of complications,2,3 and their avoidance may further decrease these complications. Because anastomotic leak from gastro-enterostomy is one of the most dreaded complications of laparoscopic RYGB, we extend Dr. Champion’s advice regarding the intraoperative methylene blue and the utilization of postoperative gastrografin swallow test.4 We utilize a 4-step intraoperative approach to assure the safety of the anastomosis. This approach includes (1) circumferential magnified inspection of the anastomosis with a 45° laparoscope. This identifies the posterior wall of the anastomosis and visualizes the complete staple line. (2) Air test—forceful instillation of air with a bulb-syringe after occlusion of the Roux limb with intestinal clamp placed approximately 10-cm distal to the gastro-enterostomy and the tip of the nasogastric tube positioned 2 to 3 cm distal to the anastomosis. (3) Forceful instillation of the 60 to 80 cc of methylene blue as confirmed by well-distended pouch and proximal portion of the occluded Roux limb. (4) Release of the clamp and additional instillation of 40 cc of methylene blue and observation of the routinely placed JP drain content in the recovery room for presence of any blue dye. PIOTR GORECKI, MD LESLIE WISE, MD Division of Laparoscopic Surgery Department of Surgery New York Methodist Hospital Brooklyn, New York

7. Higa KD, Boone KB, Ho T. Complications of the laparo-

scopic Roux-en-Y gastric bypass: 1040 patients- what have we learned? Obes Surg. 2000;10:509-513. 8. De la Torre RA, Scott JS. Laparoscopic Roux-en-Y gastric

bypass: a totally intra-abdominal approach- technique and preliminary report. Obes Surg. 1999;9:492-497. 9. Champion JK. The role of routine intraoperative endos-

copy in laparoscopic bariatric surgery. Surg Endosc. 2002; 16:S213. 10. Champion JK. The route of the roux in laparoscopic gas-

tric bypass— does it matter? Obes Surg. 2001;11:159. 11. Champion JK. Small bowel obstruction after laparoscopic

Roux-en-Y gastric bypass. Obes Surg. 2002;12:197-198. 12. Felix EL, Brown JE. Preventing small bowel obstruction

after laparoscopic Roux-en-Y gastric bypass. Obes Surg. 2002;12:197.

REFERENCES 1. Nguyen NT, Goldman C, Rosenquist CJ, et al. Laparo-

scopic versus open gastric bypass: a randomized study of outcomes, quality of life, and costs. Ann Surg. 2001;234: 279-289; discussion 289-291. 2. Nguyen NT, Wolfe BM. Hypopharyngeal perforation dur-

ing laparoscopic Roux-en-Y gastric bypass. Obes Surg. 2000; 10:64-67. 3. Higa KD, Boone KB, Ho T. Complications of the laparo-

scopic Roux-en-Y gastric bypass: 1,040 patients—what have we learned? Obes Surg. 2000;10:509-513.

13. Higa KD, Ho T, Boone KB. Internal hernias after laparo-

4. Amarasinghe DC. Air test as an alternative to methylene

scopic Roux-en-Y gastric bypass: incidence, treatment and prevention. Obes Surg. 2002;12:197.

blue test foe leaks. Correspondence. Obes Surg. 2002;12: 295-296.

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