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Do We Really Need to Close Internal Hernia Spaces?
S92
Poster Presentations / Surgery for Obesity and Related Diseases 11 (2015) S56–S211
Methods: We interrogated a prospectively maintained database of consecutive primary laparoscopic Roux en-Y gastric bypass (LRYGB) performed from Sept 09 to Mar 13 in a UK regional bariatric centre. Demographics, preoperative co-morbidities, operative outcomes, excess weight loss (EWL) and remission of diabetes at 12months were compared in patients aged 455 and r55 years. Results: LRYGB was completed laparoscopically in 304 patients (220 [72%] female) of which 80 (26%) were aged 455. Median (IQR) age was 44 (39-54) and 61 (58-68) years in each respective group (Po0.0001) with no gender differences (P¼0.70). Mean⫾SD baseline body mass index (BMI) was 54⫾6.9 and 52⫾6.5 kg/m2 in the r55 and 455 groups respectively (P¼0.40). There was a significantly higher incidence of comorbidities (diabetes, hypertension, ischemic heart diseases, sleep apnea, and arthritis) in the older group (Po0.001). No postoperative mortality occurred in either group. There was no difference in occurrence of early or late postoperative complications. At 12-month follow up, there was comparable EWL [median (IQR) 72 (54-83) % vs 67 (53-83) %, P¼0.80], and diabetes remission [75% vs 82%, P¼0.46] in patients aged r55 vs 455 years, respectively. Conclusions: Although older morbidly obese patients have higher incidence of obesity-related co-morbidities, LRYGB provides benefits akin to those seen in younger patients. Age, per se, should not preclude older patients being considered for LRYGB.
A5068
DO WE REALLY NEED TO CLOSE INTERNAL HERNIA SPACES? Ahmed Ahmed1; Iris Sanchez-Egido, MD2; 1Imperial College London, London, UK; 2Hospital Sureste, Madrid, Spain Background: Internal hernia (IH) is a known complication after gastric bypass. This study describes our experience with using an antecolic antegastric Roux limb without division of mesentery and without closure of IH defects and its effect on the incidence of IH. Method: A retrospective chart review was performed of all patients undergoing a standard antecolic antegastric technique without division of mesentery and without closure of IH spaces (AA-LRYGB) between January 2008 and June 2010. Furthermore, a comparison was made in IH rates with a historical sample of retrocolic retrogastric LRYGB with mesenteric division and IH defect closure. Results: Two internal hernias occurred in 212 patients followed up for 25 months (13-35 months), an incidence of 0.9%.The site of internal hernia was at Petersen’s defect for one patient and at the jejuno-jejunostomy for the other. The mean time to intervention for an internal hernia repair was 355 days and average % excess body weight loss (%EBWL) in this period was 78%. The historical retrocolic retrogastric group with mesentery division and IH defect closure, had IH in 52 cases (23 transverse mesocolon, 22 jejunojejunostomy, 7 Petersen’s defect) out of 2215 patients, an incidence of 2.4%. Conclusion: The results of this study demonstrate that in our hands using an antecolic antegastric approach without division of small bowel mesentery and closure of IH spaces, the incidence of internal hernia is less than the incidence seen when we routinely closed all internal hernia defects in the retrocolic retrogastric LRYGB. One potential explanation for this rather paradoxical finding is that in the non mesentery division technique, large
redundant spaces are created through which loops of small bowel may displace in and out without becoming stuck. In cases where IH defects are routinely closed, with weight loss, gaps in the mesentery may develop thereby trapping small bowel loops. A5069
OUTCOMES OF POSTERIOR CRURAL REPAIR IN MORBIDLY OBESE PATIENTS UNDERGOING LAPAROSCOPIC ROUX EN-Y GASTRIC BYPASS Waleed Al-Khyatt, PhD, MRCS; Sherif Awad, PhD, FRCS; Javed Ahmed, MBBS FRCSI; The East-Midlands Bariatric & Metabolic Institute (EMBMI), Royal Derby Hospital, Derby Teaching Hospitals NHS Foundation Trust, Derby, UK Background: In patients undergoing laparoscopic insertion of gastric band or sleeve gastrectomy simultaneous repair of hiatus hernia (HH) improves outcomes. Hitherto, there is paucity of data on the effects of simultaneous repair of HH found during laparoscopic Roux en-Y Gastric Bypass (LRYGB). We studied the outcomes of LRYGB with simultaneous HH repair (LRYGBHH) compared to LRYGB only. Methods: We analyzed a prospectively maintained database of 304 consecutive LRYGB performed from Sept 09 to Mar 13. Data included patient demographics, baseline co-morbidities, operative outcomes, % excess weight loss (EWL) and diabetes remission at 12-months. Outcomes were compared for patients who underwent LRYGB-HH (posterior crural suture repair) vs LRYGB only. Results: LRYGB was performed in 280 patients whilst 24 (8%) underwent LRYGB-HH. Median (IQR) age and mean⫾SD body mass index (BMI) at presentation were 48 (41-56) vs 54 (48-59) years (P¼0.02), and 54⫾6.7 vs 52⫾8.1 kg/m2 (P¼0.10) for LRYGB and LRYGB-HH, respectively. There were no differences in baseline co-morbidities (diabetes, hypertension, ischemic heart diseases, & sleep apnea). Preoperative reflux symptoms occured more common in patients who needed simultaneous HH repair (Po0.0001). Respective mean⫾SD operating times were 124⫾33 and 139⫾32 min for LRYGB and LRYGB-HH (P¼0.10). There were three postoperative complications in the LRYGB-HH group (one postoperative bleed and two anastomotic strictures that required OGD & dilatation). There were no instances of postoperative dysphagia relating to posterior crural repair in the LRYGB-HH group. At 12-month follow-up, there was comparable EWL (mean⫾SD 70⫾20% vs 65⫾13 %, P¼0.30), and diabetes remission (87% vs 80%, P¼0.20) for LRYGB-HH and LRYGB respectively. Conclusions: LRYGB with simultaneous posterior crural HH repair in patients with significant preoperative reflux symptoms was safe, feasible, and associated with low postoperative morbidity.
A5070
SAFETY AND EFFICACY OF STAND-ALONE OPTICAL TROCAR ACCESS IN LAPAROSCOPIC GASTRIC BYPASS PATIENTS WITH MULTIPLE PRIOR ABDOMINAL OPERATIONS Ann Rogers, MD1; Susana Ho, BS2; 1Penn State Hershey Medical Center, Hershey, PA; 2Penn State University College of Medicine, Hershey, PA, USA
Poster Presentations / Surgery for Obesity and Related Diseases 11 (2015) S56–S211
Methods: We interrogated a prospectively maintained database of consecutive primary laparoscopic Roux en-Y gastric bypass (LRYGB) performed from Sept 09 to Mar 13 in a UK regional bariatric centre. Demographics, preoperative co-morbidities, operative outcomes, excess weight loss (EWL) and remission of diabetes at 12months were compared in patients aged 455 and r55 years. Results: LRYGB was completed laparoscopically in 304 patients (220 [72%] female) of which 80 (26%) were aged 455. Median (IQR) age was 44 (39-54) and 61 (58-68) years in each respective group (Po0.0001) with no gender differences (P¼0.70). Mean⫾SD baseline body mass index (BMI) was 54⫾6.9 and 52⫾6.5 kg/m2 in the r55 and 455 groups respectively (P¼0.40). There was a significantly higher incidence of comorbidities (diabetes, hypertension, ischemic heart diseases, sleep apnea, and arthritis) in the older group (Po0.001). No postoperative mortality occurred in either group. There was no difference in occurrence of early or late postoperative complications. At 12-month follow up, there was comparable EWL [median (IQR) 72 (54-83) % vs 67 (53-83) %, P¼0.80], and diabetes remission [75% vs 82%, P¼0.46] in patients aged r55 vs 455 years, respectively. Conclusions: Although older morbidly obese patients have higher incidence of obesity-related co-morbidities, LRYGB provides benefits akin to those seen in younger patients. Age, per se, should not preclude older patients being considered for LRYGB.
A5068
DO WE REALLY NEED TO CLOSE INTERNAL HERNIA SPACES? Ahmed Ahmed1; Iris Sanchez-Egido, MD2; 1Imperial College London, London, UK; 2Hospital Sureste, Madrid, Spain Background: Internal hernia (IH) is a known complication after gastric bypass. This study describes our experience with using an antecolic antegastric Roux limb without division of mesentery and without closure of IH defects and its effect on the incidence of IH. Method: A retrospective chart review was performed of all patients undergoing a standard antecolic antegastric technique without division of mesentery and without closure of IH spaces (AA-LRYGB) between January 2008 and June 2010. Furthermore, a comparison was made in IH rates with a historical sample of retrocolic retrogastric LRYGB with mesenteric division and IH defect closure. Results: Two internal hernias occurred in 212 patients followed up for 25 months (13-35 months), an incidence of 0.9%.The site of internal hernia was at Petersen’s defect for one patient and at the jejuno-jejunostomy for the other. The mean time to intervention for an internal hernia repair was 355 days and average % excess body weight loss (%EBWL) in this period was 78%. The historical retrocolic retrogastric group with mesentery division and IH defect closure, had IH in 52 cases (23 transverse mesocolon, 22 jejunojejunostomy, 7 Petersen’s defect) out of 2215 patients, an incidence of 2.4%. Conclusion: The results of this study demonstrate that in our hands using an antecolic antegastric approach without division of small bowel mesentery and closure of IH spaces, the incidence of internal hernia is less than the incidence seen when we routinely closed all internal hernia defects in the retrocolic retrogastric LRYGB. One potential explanation for this rather paradoxical finding is that in the non mesentery division technique, large
redundant spaces are created through which loops of small bowel may displace in and out without becoming stuck. In cases where IH defects are routinely closed, with weight loss, gaps in the mesentery may develop thereby trapping small bowel loops. A5069
OUTCOMES OF POSTERIOR CRURAL REPAIR IN MORBIDLY OBESE PATIENTS UNDERGOING LAPAROSCOPIC ROUX EN-Y GASTRIC BYPASS Waleed Al-Khyatt, PhD, MRCS; Sherif Awad, PhD, FRCS; Javed Ahmed, MBBS FRCSI; The East-Midlands Bariatric & Metabolic Institute (EMBMI), Royal Derby Hospital, Derby Teaching Hospitals NHS Foundation Trust, Derby, UK Background: In patients undergoing laparoscopic insertion of gastric band or sleeve gastrectomy simultaneous repair of hiatus hernia (HH) improves outcomes. Hitherto, there is paucity of data on the effects of simultaneous repair of HH found during laparoscopic Roux en-Y Gastric Bypass (LRYGB). We studied the outcomes of LRYGB with simultaneous HH repair (LRYGBHH) compared to LRYGB only. Methods: We analyzed a prospectively maintained database of 304 consecutive LRYGB performed from Sept 09 to Mar 13. Data included patient demographics, baseline co-morbidities, operative outcomes, % excess weight loss (EWL) and diabetes remission at 12-months. Outcomes were compared for patients who underwent LRYGB-HH (posterior crural suture repair) vs LRYGB only. Results: LRYGB was performed in 280 patients whilst 24 (8%) underwent LRYGB-HH. Median (IQR) age and mean⫾SD body mass index (BMI) at presentation were 48 (41-56) vs 54 (48-59) years (P¼0.02), and 54⫾6.7 vs 52⫾8.1 kg/m2 (P¼0.10) for LRYGB and LRYGB-HH, respectively. There were no differences in baseline co-morbidities (diabetes, hypertension, ischemic heart diseases, & sleep apnea). Preoperative reflux symptoms occured more common in patients who needed simultaneous HH repair (Po0.0001). Respective mean⫾SD operating times were 124⫾33 and 139⫾32 min for LRYGB and LRYGB-HH (P¼0.10). There were three postoperative complications in the LRYGB-HH group (one postoperative bleed and two anastomotic strictures that required OGD & dilatation). There were no instances of postoperative dysphagia relating to posterior crural repair in the LRYGB-HH group. At 12-month follow-up, there was comparable EWL (mean⫾SD 70⫾20% vs 65⫾13 %, P¼0.30), and diabetes remission (87% vs 80%, P¼0.20) for LRYGB-HH and LRYGB respectively. Conclusions: LRYGB with simultaneous posterior crural HH repair in patients with significant preoperative reflux symptoms was safe, feasible, and associated with low postoperative morbidity.
A5070
SAFETY AND EFFICACY OF STAND-ALONE OPTICAL TROCAR ACCESS IN LAPAROSCOPIC GASTRIC BYPASS PATIENTS WITH MULTIPLE PRIOR ABDOMINAL OPERATIONS Ann Rogers, MD1; Susana Ho, BS2; 1Penn State Hershey Medical Center, Hershey, PA; 2Penn State University College of Medicine, Hershey, PA, USA