- Email: [email protected]
One-stage robotically assisted laparoscopic biliopancreatic diversion with duodenal switch: analysis of 179 patients
Surgery for Obesity and Related Diseases 11 (2015) 367–371
Original article
One-stage robotically assisted laparoscopic biliopancreatic diversion with duodenal switch: analysis of 179 patients Gintaras Antanavicius, M.D., F.A.C.S.*, Masoud Rezvani, M.D., F.A.C.S., Iswanto Sucandy, M.D. Department of Surgery, Institute for Bariatric and Metabolic Surgery, Abington Memorial Hospital, Abington, Pennsylvania Received March 12, 2014; accepted October 26, 2014
Abstract
Background: Biliopancreatic diversion with duodenal switch (BPD-DS) has been reported to be the most effective procedure for weight loss and minimizing postoperative weight regain. However, because of its technical complexity and concerns for higher operative and metabolic complications, it has not obtained widespread acceptance among patients or bariatric surgeons. Nevertheless, the use of robotic systems has been increasing because of its ability to overcome technical challenges, such as torque, freedom of movement, and precision. The objective of this study was to review the efficacy and safety of robotic assistance in laparoscopic BPD-DS. Methods: A prospectively maintained database of patients who underwent robotic-assisted laparoscopic BPD-DS between 2008 and 2013 was reviewed retrospectively. Results: A total of 179 consecutive patients (137 female and 42 male) were included in the study. The mean age was 44 years (20–72 yr). Mean body mass index (BMI) was 50.3 kg/m2 (35–78.8 kg/ m2), and the number of preoperative co-morbidities was 6.6 (2–14). Mean operative time for a typical BPD-DS with appendectomy was 249 minutes (162–413 min), which increased to 278 minutes (193– 463 min) in adhesiolysis associated cases and increased to 272 minutes (186–431 min) if additional procedures, such as hiatal hernia repair, cholecystectomy, or Meckel’s diverticulum resection, were included. All procedures were completed as a single-stage operation. There were no major intraoperative complications. Two patients had unexpected returns to the operating room during the same admission: one for an endoscopic release of an inadvertently sutured nasogastric tube and the other for port site infection. Median hospital stay was 2.7 days (1–13). Two patients had significantly longer stays for carpal tunnel syndrome exacerbation (9 d) and port site infection (13 d). Postoperatively, the median excess weight loss at 1, 3, 6, 9, 12, 18, 24, and 36 months with follow-up of 71% of patients at 1 year, 45% of patients at 2 years, and 15% of patients at 5 years, was 19%, 35.9%, 53.1%, 65.6%, 74.6%, 79.9%, and 75.8%, respectively. Diabetes, hypertension, and hyperlipidemia went into remission 95.5%, 92.1%, and 92% of the time, respectively. No mortality occurred. Conclusions: Robotically assisted duodenoileal anastomosis during laparoscopic BPD-DS is a feasible, well-tolerated, and effective alternative to assist in the technically challenging part of the operation. (Surg Obes Relat Dis 2015;11:367–371.) r 2015 American Society for Metabolic and Bariatric Surgery. All rights reserved.
Keywords:
Biliopancreatic diversion with duodenal switch; Robotic-assisted; Morbid obesity
Poster presentation at American Society of Bariatric and Metabolic Surgery, Obesity Week Annual Meeting 2013, Atlanta, Georgia. * Correspondence: Gintaras Antanavicius, M.D., F.A.C.S., F.A.S.M.B. S., Institute for Metabolic and Bariatric Surgery, 225 Newtown Road, Warminster, PA 18974. E-mail: [email protected]
Biliopancreatic diversion with duodenal switch (BPDDS) is generally considered for super morbidly obese patients, defined as body mass index (BMI) Z50 kg/m2 [1]. These patients often have a high number of obesityrelated co-morbidities, which are accompanied by a greater
http://dx.doi.org/10.1016/j.soard.2014.10.023 1550-7289/r 2015 American Society for Metabolic and Bariatric Surgery. All rights reserved.
368
G. Antanavicius et al. / Surgery for Obesity and Related Diseases 11 (2015) 367–371
risk of procedure-related complications postoperatively. In addition, some technical factors in super morbidly obese patients, such as central obesity, short mesentery, and lack of adequate intraperitoneal space, make the technical part of BPD-DS more challenging. For those reasons, BPD-DS is considered to be the most challenging bariatric procedure, despite its great degree of weight loss and resolution of comorbidities such as diabetes mellitus [2–4]. Because of this concern, many authors have advocated a 2-stage approach: A vertical sleeve gastrectomy (VSG) is performed at the first stage, followed by a duodenal switch procedure after initial weight loss [4–6]. In the authors’ institution, BPD-DS is strongly considered for super morbidly obese patients. The present study was designed to review the use of robotic assistance along with the laparoscopic technique in patients who underwent BPD-DS. The morbidly and mortality rate of BPD-DS was assessed, as well as outcomes and complications in those patients. Methods The records of 179 consecutive patients who underwent robotic-assisted laparoscopic BPD-DS for morbid obesity, performed by our bariatric surgeon at an independent teaching hospital from December 2008 to February 2013, were retrospectively analyzed. Patients who underwent revision of prior weight loss procedures or conversion to BPD-DS were excluded from the study. Demographic data, such as age, sex, and BMI, were obtained from a prospectively maintained database. More detailed information, such as the operative time, length of the hospital stay (LOS), immediate postoperative complication, and unexpected 30day emergency room admission, was obtained from individual chart review. All patients were fully evaluated by a bariatric surgeon, bariatric nutritionist, bariatric psychiatrist, and, in appropriate and necessary situations, by a cardiologist and a pulmonologist. Every patient underwent a standard protocol of blood work, electrocardiogram, and imaging studies. Before the procedure, a standard deep vein thrombosis prophylaxis protocol, which included continuous bilateral lower extremity sequential compression stockings and 5000 units of subcutaneous heparin injection, was applied to all patients. The procedure was initiated laparoscopically by placing 2 5-mm trocars and 4 12-mm trocars (Fig. 1). It was then continued to VSG, guided by bougie. A 42F bougie was used as a guide, but care was taken to ensure that the tissue around the bougie was loose, with an effective sleeve size of approximately 60F or more; strictures or tight sleeves may predispose these patients to malnutrition. Then, the VSG was followed by duodenal dissection and duodenal division 2–3 cm from the pylorus by using a 3.5-mm linear stapler. Some situations, such as prior pancreatitis or perforated duodenal ulcer, made this step more challenging.
Fig. 1. Port placement for robotic-assisted laparoscopic biliopancreatic diversion with duodenal switch.
However, a meticulous laparoscopic dissection was adequate to complete this portion of the procedure. At 250 cm from the ileocecal valve, the small bowel was attached to the proximal part of divided duodenum by using laparoscopic posterior outer layer suturing technique. Subsequently, the jejunum was divided at the duodenoileal connection to separate the alimentary limb from the biliopancreatic (BP) limb. Then the BP limb was brought down to a 100-cm distance from the ileocecal valve, and an ileoileal anastomosis was constructed by using a 2.5-mm linear stapler. At this point, the 2 robot operator arms with needle holders were introduced through trocars No. 2 and No. 4, and the robot camera was placed through trocar No. 3 (Fig. 1). The remainder of duodenoileal anastomosis was then completed by using the robotic arms hand-sewn 2layer Connell suturing technique. A 3-0 Vicryl stitch was used on both inner and outer layers (VICRYL TM; Ethicon, Somervile, NJ, USA). If additional procedures, such as lysis of adhesion, hiatal hernia repair, appendectomy, and cholecystectomy, were necessary, they were performed laparoscopically before use of the robotic system. No roboticassisted BPD-DS patient was converted to open procedure. All patients were seen for follow-up appointments at 1 week, 1 month, 3 months, 6 moths, 12 months, and 18 months after the procedure. Electronic medical charts from office follow-up visits, emergency room encounters, and hospital admissions in the 30-day period postoperatively were reviewed to assess the patient outcome, any potential complication, and unplanned postoperative admissions. Results A total of 179 patients were included in the study. The patient population consisted primarily of women (76.5%) (Table 1). The mean age for all individuals was 44.2 years
One-Stage Operation with Robotic Assistance / Surgery for Obesity and Related Diseases 11 (2015) 367–371 Table 1 Patient demographic data Age, yr Sex (female/male) Body mass index, kg/m2 Preoperative co-morbidities
369
Table 3 Operative time, 30-day outcome, and complication rate after BPD-DS 44.2 (20–72) 137/42 50.3 (35–78.8) 6.62 (2–14)
(range 20–72). The mean BMI was 50.3 kg/m2 (35–78.8), and the number of preoperative obesity-related co-morbidities was 6.6 (2–14) (Table 2). Diagnosis of type 2 diabetes mellitus (DM) was based on fasting blood sugar Z125 mg/ dL or random blood sugar Z200 mg/dL. Patients with systolic blood pressure Z140 mm Hg were considered hypertensive, and individuals with total cholesterol Z200 mg/dL or LDL Z130 mg/dL were also considered hyperlipidemic patients. Mean operative time for a roboticassisted laparoscopic BPD-DS with appendectomy was 249 minutes (range: 162–413). For some individuals for whom other procedures such as lysis of adhesion were necessary, the mean operative time increased to 278 minutes (193–463). In cases with additional required procedures, such as hiatal hernia repair, cholecystectomy, and Meckel diverticulum resection, operative time was calculated to be 272 minutes (range: 186–431) (Table 3). Operative time decreased progressively as experience increased (Fig. 2). The robotic time and laparoscopic time was not documented separately on the operative room sheets; however, the entire estimated docking and undocking time, including robotic positioning on the patient’s body, was approximately 15 minutes or less. No major intraoperative complications were experienced, and no operation was converted to an open procedure. Two patients had unplanned returns to the operating room: One patient had an inadvertently sutured nasogastric tube that was released endoscopically, and the other experienced a significant port site wound infection that turned into an abscess. She underwent laparoscopic exploration, formal wound exploration, and incision and drainage of the abscess. The length of hospital stay ranged from 1–13 Table 2 Preoperative co-morbidities Preoperative co-morbidities
Prevalence, %
Diabetes mellitus Hypertension Hyperlipidemia Obstructive sleep apnea Back pain Osteoarthritis Gastroesophageal reflux disease Hepatic steatosis Asthma Pseudotumor cerebri Depression Stress urinary incontinence
34 49 39 84 22 79 53 2 6 o1 26 14
Mean operative time, min Typical BPD-DS BPD-DS with adhesiolysis BPD-DS with other procedure Complications Anastomosis leak Hemorrhage Intraluminal Extraluminal Subcutaneous Intestinal obstruction Injury to other organs Venous thromboembolism (DVT, PE) Inadvertently sutured nasogastric tube Port site infection Other* Median length of stay (d) 30-d hospital readmissions Epigastric pain (required pain medication adjustment) Fluid retention (required aggressive diuresis) Incarcerated ventral hernia (required hernia repair procedure) Gastrointestinal bleeding (required blood transfusion) DVT/PE (required full anticoagulation)
249 (162–413) 278 (193–463) 272 (186–431) 0 1 0 0 0 0 1 1 1 1 2.7 (1–13) 1 1 1 1 1
Abbreviations: BPD-DS ¼ biliopancreatic diversion with duodenal switch; DVT ¼ deep vein thrombosis; PE ¼ pulmonary embolism. * Carpal tunnel syndrome exacerbation.
days with a median stay of 2.7 days. Two patients had significantly longer hospital stays. One was caused by worsening preexisting carpal tunnel syndrome that lasted 9 days and resolved spontaneously. Another patient had a prolonged hospital stay of 13 days as a result of incision and drainage port site wound and daily packing. Five patients were readmitted within 30 days after discharge from the hospital. One patient presented with fluid retention, which resulted in lower extremity edema and shortness of breath. One patient presented with preexisting incarcerated ventral hernia that was not repaired at the first procedure. One patient experienced lower gastrointestinal bleeding after swallowing an orange, whole, shortly after the procedure and presumably overstretched or traumatized her VSG staple line. This complication was resolved with blood transfusion and conservative management. One patient had significant epigastric pain and nausea of unknown origin, which was cured by intravenous fluid and analgesics. One patient presented with deep vein thrombosis and pulmonary embolism and was treated at a different facility with full anticoagulation (Table 3). Postoperatively, 100% of patients at 9 months, 71% of patients at 1 year, 45% of patients at 2 years, and 15% of patients at 5 years returned to the office for follow-up visits. In 1-, 3-, 6-, 9-, 12-, 18-, 24-, and 36-month follow-ups, patients experienced 19%, 35.9%, 53.1%, 65.5%, 74.6%,
370
G. Antanavicius et al. / Surgery for Obesity and Related Diseases 11 (2015) 367–371
Fig. 2. Operative time.
79.9%, and 75.8% excess weight loss, respectively. In postoperative follow-up, remission was defined as complete disappearance of co-morbidity, such as DM, according to the preoperative parameters with discontinuation of medications, and improvement was defined as persistence of the diseases according to the parameters, although with lesser amount or lower dosage of medications; 95.5% of diabetic patients had remission, and 4.6% experienced improvement. Patients with preoperative associated hypertension had 92.1% remission and 7.9% improvement. Individuals with hyperlipidemia had 92% remission, 5% improvement, and 3% no change in follow-up. No BPD-DS–related mortality occurred in this study up to 36 months after the procedure. Discussion The excellent outcome and maintenance of long-term weight loss, as well as correction of obesity-related comorbidities after BPD-DS, are well defined in the literature [2,7,8]. In a meta-analysis of weight loss surgery data, Buchwald et al. reported that BPD-DS provides the best long-term weight loss maintenance (70.1%) and complete or near complete resolution of DM (98%) with a mortality rate of 1.1% [9]. Other studies by Fazylov et al., Ren et al., and Spyropoulos et al. have reported a significant mortality rate to a maximum of 12.5%, especially in super morbidly obese patients (BMI 450 kg/m2) [10–12]. Technical challenges, especially constructing duodenoileal anastomoses, likely play a significant role in morbidity and mortality rates. Different techniques have been used to minimize the challenge. Weiner et al. reported 3 different laparoscopic techniques in creating duodenoileal anastomoses in a total of 63 patients [16]. These techniques included using a 21mm circular stapler, a side-to-side linear stapler to create posterior wall, a running hand-sewn Vicryl stitch to make anterior wall, and a complete hand-sewn anastomosis by
using 2-0 polypropylene stitch. One of 21 patients in the circular stapler group experienced an anastomosis leak and 3 others developed an abdominal wound infection at the side of circular stapler insertion. It was concluded that combined side-to-side linear stapling and hand-sewn anastomosis was the most well-tolerated technique with a comparable operative room time. Sudan et al. reported the first series of robotic BPD-DS in 2000 and described 4 anastomosis leaks without mortality in 47 patients. The incidence of leak was thought to be related to a lack of adequate surgeon experience and a high learning curve for this very complex procedure. The learning curve was estimated to be around 50 cases, at which point the complication rate tended to plateau. In a recent report of 80 patients who underwent robotic BPD-DS by Sudan et al., the operative duration decreased by an average of 3 minutes with each successive case (P o .001, R² ¼ .63). The incidence of high blood loss (13.3%), conversion (2.2%), and leaks (5.8%) were experienced by a total of 22 patients (18.3%) [13–15]. In the present series, the robot system was used in constructing duodenoileal anastomosis in a similar manner as described by Sudan et al. The robotic approach offers superior visualization of the duodenal stump and allows for the ability to have 180-degree wrist rotation and precision to perform hand-sewn anastomosis. Other benefits, such as 3dimensional vision, minimization of tremor, and elimination of image reversal, aid in creating a better technical approach for performing the anastomosis. Robotic arms prevent transmission of tissue toque related to abdominal wall thickness and provide precision throughout the procedure. Although mastery of the laparoscopic suturing technique is beneficial, the authors believe that the robotic system may offer some advantage in perfecting duodenoileal anastomosis. In the present series, no technical complications were experienced, especially leaks related to duodenoileal anastomosis. A disadvantage of this technique includes the potential cost and time for using robotic system, which arguably can be
One-Stage Operation with Robotic Assistance / Surgery for Obesity and Related Diseases 11 (2015) 367–371
minimized in high-volume centers. The other disadvantage is the absence of tactile feedback. More studies and data analysis will be needed, but it is likely that new, cheaper robotic systems will ultimately become widely adopted. Conclusions Robotic assistance is useful in performing BPD-DS. It is a well-tolerated and potentially useful tool that offers the benefits of good visualization, more precise maneuverability, elimination of tremor, ability to adapt to patients’ technical limitations, and image reversal during performance of hand-sewn anastomosis. Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article. References [1] Mechanick JI, Kushner RF, Sugerman HJ, et al. American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guideline for Clinical Practice for the preoperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient. Surg Obes Relat Dis 2008;4(Suppl 5):S84–109. [2] Duckworth W, Abraira C, Moritz T, et al. Glucose control and vascular complications in veterans with type 2 diabetes. N Engl J Med 2009;360:129–39. [3] Buchwald H, Estok R, Fahrbach K, Banel D, Sledge I. Trends in mortality in bariatric surgery: a systematic review and meta-analysis. Surgery 2007;142:621–32. [4] Kim WW, Gagner M, Kini S, et al. Laparoscopic vs. open biliopancreatic diversion with duodenal switch: a comparative study. J Gastrointest Surg 2003;4:552–7.
371
[5] Topart P, Becouarn G, Ritz P. Should biliopancreatic diversion with duodenal switch be done as single-stage procedure in patients with BMI Z50 kg/m2? Surg Obes Relat Dis 2010;6:59–63. [6] Cottam D, Qureshi FG, Mattar SG, et al. Laparoscopic sleeve gastrectomy as an initial weight-loss procedure for high-risk patients with morbid obesity. Surg Endosc 2006;20:859–63. [7] Parikh MS, Shen R, Weiner M, Siegel N, Ren CJ. Laparoscopic bariatric surgery in super-obese patients (BMI 450) is safe and effective: a review of 332 patients. Obes Surg 2005;15: 858–63. [8] Stephens DJ, Saunders JK, Belsley S, et al. Short-term outcomes for super-super obese (BMI Z60 kg/m2) patients undergoing weight loss surgery at a high-volume bariatric surgery center: laparoscopic adjustable gastric banding, laparoscopic gastric bypass, and open tubular gastric bypass. Surg Obes Relat Dis 2008;4:408–15. [9] Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA 2004;292:1724–37. [10] Ren CJ, Patterson E, Gagner M. Early results of laparoscopic biliopancreatic diversion with duodenal switch: a case series of 40 consecutive patients. Obes Surg 2000;10:514–23. [11] Fazylov RM, Savel RH, Horovitz JH, et al. Association of supersuper-obesity and male gender with elevated mortality in patients undergoing the duodenal switch procedure. Obes Surg 2005;15: 618–23. [12] Spyropoulos C, Bakellas G, Skroubis G, et al. A prospective evaluation of a variant of biliopancreatic diversion with Roux-en-Y reconstruction in mega-obese patients (BMI Z70 kg/m2). Obes Surg 2008;18:803–9. [13] Sudan R, Puri V, Sudan D. Robotically assisted biliary pancreatic diversion with a duodenal switch: a new technique. Surg Endosc 2007;21:729–33. [14] Sudan R, Bennett KM, Jacobs DO, Sudan DL. Multifactorial analysis of the learning curve for robot-assisted laparoscopic biliopancreatic diversion with duodenal switch. Ann Surg 2012;255:940–5. [15] Buchs NC, Pugin F, Bucher P, et al. Learning curve for robot-assisted Roux-en-Y gastric bypass. Surg Endosc 2012;4:1116–21. [16] Weiner RA, Blanco-Engert R, Weiner S, Pomhoff I, Schramm M. Laparoscopic biliopancreatic diversion with duodenal switch: three different duodeno-ileal anastomotic techniques and initial experience. Obes Surg 2004;3:334–40.
Original article
One-stage robotically assisted laparoscopic biliopancreatic diversion with duodenal switch: analysis of 179 patients Gintaras Antanavicius, M.D., F.A.C.S.*, Masoud Rezvani, M.D., F.A.C.S., Iswanto Sucandy, M.D. Department of Surgery, Institute for Bariatric and Metabolic Surgery, Abington Memorial Hospital, Abington, Pennsylvania Received March 12, 2014; accepted October 26, 2014
Abstract
Background: Biliopancreatic diversion with duodenal switch (BPD-DS) has been reported to be the most effective procedure for weight loss and minimizing postoperative weight regain. However, because of its technical complexity and concerns for higher operative and metabolic complications, it has not obtained widespread acceptance among patients or bariatric surgeons. Nevertheless, the use of robotic systems has been increasing because of its ability to overcome technical challenges, such as torque, freedom of movement, and precision. The objective of this study was to review the efficacy and safety of robotic assistance in laparoscopic BPD-DS. Methods: A prospectively maintained database of patients who underwent robotic-assisted laparoscopic BPD-DS between 2008 and 2013 was reviewed retrospectively. Results: A total of 179 consecutive patients (137 female and 42 male) were included in the study. The mean age was 44 years (20–72 yr). Mean body mass index (BMI) was 50.3 kg/m2 (35–78.8 kg/ m2), and the number of preoperative co-morbidities was 6.6 (2–14). Mean operative time for a typical BPD-DS with appendectomy was 249 minutes (162–413 min), which increased to 278 minutes (193– 463 min) in adhesiolysis associated cases and increased to 272 minutes (186–431 min) if additional procedures, such as hiatal hernia repair, cholecystectomy, or Meckel’s diverticulum resection, were included. All procedures were completed as a single-stage operation. There were no major intraoperative complications. Two patients had unexpected returns to the operating room during the same admission: one for an endoscopic release of an inadvertently sutured nasogastric tube and the other for port site infection. Median hospital stay was 2.7 days (1–13). Two patients had significantly longer stays for carpal tunnel syndrome exacerbation (9 d) and port site infection (13 d). Postoperatively, the median excess weight loss at 1, 3, 6, 9, 12, 18, 24, and 36 months with follow-up of 71% of patients at 1 year, 45% of patients at 2 years, and 15% of patients at 5 years, was 19%, 35.9%, 53.1%, 65.6%, 74.6%, 79.9%, and 75.8%, respectively. Diabetes, hypertension, and hyperlipidemia went into remission 95.5%, 92.1%, and 92% of the time, respectively. No mortality occurred. Conclusions: Robotically assisted duodenoileal anastomosis during laparoscopic BPD-DS is a feasible, well-tolerated, and effective alternative to assist in the technically challenging part of the operation. (Surg Obes Relat Dis 2015;11:367–371.) r 2015 American Society for Metabolic and Bariatric Surgery. All rights reserved.
Keywords:
Biliopancreatic diversion with duodenal switch; Robotic-assisted; Morbid obesity
Poster presentation at American Society of Bariatric and Metabolic Surgery, Obesity Week Annual Meeting 2013, Atlanta, Georgia. * Correspondence: Gintaras Antanavicius, M.D., F.A.C.S., F.A.S.M.B. S., Institute for Metabolic and Bariatric Surgery, 225 Newtown Road, Warminster, PA 18974. E-mail: [email protected]
Biliopancreatic diversion with duodenal switch (BPDDS) is generally considered for super morbidly obese patients, defined as body mass index (BMI) Z50 kg/m2 [1]. These patients often have a high number of obesityrelated co-morbidities, which are accompanied by a greater
http://dx.doi.org/10.1016/j.soard.2014.10.023 1550-7289/r 2015 American Society for Metabolic and Bariatric Surgery. All rights reserved.
368
G. Antanavicius et al. / Surgery for Obesity and Related Diseases 11 (2015) 367–371
risk of procedure-related complications postoperatively. In addition, some technical factors in super morbidly obese patients, such as central obesity, short mesentery, and lack of adequate intraperitoneal space, make the technical part of BPD-DS more challenging. For those reasons, BPD-DS is considered to be the most challenging bariatric procedure, despite its great degree of weight loss and resolution of comorbidities such as diabetes mellitus [2–4]. Because of this concern, many authors have advocated a 2-stage approach: A vertical sleeve gastrectomy (VSG) is performed at the first stage, followed by a duodenal switch procedure after initial weight loss [4–6]. In the authors’ institution, BPD-DS is strongly considered for super morbidly obese patients. The present study was designed to review the use of robotic assistance along with the laparoscopic technique in patients who underwent BPD-DS. The morbidly and mortality rate of BPD-DS was assessed, as well as outcomes and complications in those patients. Methods The records of 179 consecutive patients who underwent robotic-assisted laparoscopic BPD-DS for morbid obesity, performed by our bariatric surgeon at an independent teaching hospital from December 2008 to February 2013, were retrospectively analyzed. Patients who underwent revision of prior weight loss procedures or conversion to BPD-DS were excluded from the study. Demographic data, such as age, sex, and BMI, were obtained from a prospectively maintained database. More detailed information, such as the operative time, length of the hospital stay (LOS), immediate postoperative complication, and unexpected 30day emergency room admission, was obtained from individual chart review. All patients were fully evaluated by a bariatric surgeon, bariatric nutritionist, bariatric psychiatrist, and, in appropriate and necessary situations, by a cardiologist and a pulmonologist. Every patient underwent a standard protocol of blood work, electrocardiogram, and imaging studies. Before the procedure, a standard deep vein thrombosis prophylaxis protocol, which included continuous bilateral lower extremity sequential compression stockings and 5000 units of subcutaneous heparin injection, was applied to all patients. The procedure was initiated laparoscopically by placing 2 5-mm trocars and 4 12-mm trocars (Fig. 1). It was then continued to VSG, guided by bougie. A 42F bougie was used as a guide, but care was taken to ensure that the tissue around the bougie was loose, with an effective sleeve size of approximately 60F or more; strictures or tight sleeves may predispose these patients to malnutrition. Then, the VSG was followed by duodenal dissection and duodenal division 2–3 cm from the pylorus by using a 3.5-mm linear stapler. Some situations, such as prior pancreatitis or perforated duodenal ulcer, made this step more challenging.
Fig. 1. Port placement for robotic-assisted laparoscopic biliopancreatic diversion with duodenal switch.
However, a meticulous laparoscopic dissection was adequate to complete this portion of the procedure. At 250 cm from the ileocecal valve, the small bowel was attached to the proximal part of divided duodenum by using laparoscopic posterior outer layer suturing technique. Subsequently, the jejunum was divided at the duodenoileal connection to separate the alimentary limb from the biliopancreatic (BP) limb. Then the BP limb was brought down to a 100-cm distance from the ileocecal valve, and an ileoileal anastomosis was constructed by using a 2.5-mm linear stapler. At this point, the 2 robot operator arms with needle holders were introduced through trocars No. 2 and No. 4, and the robot camera was placed through trocar No. 3 (Fig. 1). The remainder of duodenoileal anastomosis was then completed by using the robotic arms hand-sewn 2layer Connell suturing technique. A 3-0 Vicryl stitch was used on both inner and outer layers (VICRYL TM; Ethicon, Somervile, NJ, USA). If additional procedures, such as lysis of adhesion, hiatal hernia repair, appendectomy, and cholecystectomy, were necessary, they were performed laparoscopically before use of the robotic system. No roboticassisted BPD-DS patient was converted to open procedure. All patients were seen for follow-up appointments at 1 week, 1 month, 3 months, 6 moths, 12 months, and 18 months after the procedure. Electronic medical charts from office follow-up visits, emergency room encounters, and hospital admissions in the 30-day period postoperatively were reviewed to assess the patient outcome, any potential complication, and unplanned postoperative admissions. Results A total of 179 patients were included in the study. The patient population consisted primarily of women (76.5%) (Table 1). The mean age for all individuals was 44.2 years
One-Stage Operation with Robotic Assistance / Surgery for Obesity and Related Diseases 11 (2015) 367–371 Table 1 Patient demographic data Age, yr Sex (female/male) Body mass index, kg/m2 Preoperative co-morbidities
369
Table 3 Operative time, 30-day outcome, and complication rate after BPD-DS 44.2 (20–72) 137/42 50.3 (35–78.8) 6.62 (2–14)
(range 20–72). The mean BMI was 50.3 kg/m2 (35–78.8), and the number of preoperative obesity-related co-morbidities was 6.6 (2–14) (Table 2). Diagnosis of type 2 diabetes mellitus (DM) was based on fasting blood sugar Z125 mg/ dL or random blood sugar Z200 mg/dL. Patients with systolic blood pressure Z140 mm Hg were considered hypertensive, and individuals with total cholesterol Z200 mg/dL or LDL Z130 mg/dL were also considered hyperlipidemic patients. Mean operative time for a roboticassisted laparoscopic BPD-DS with appendectomy was 249 minutes (range: 162–413). For some individuals for whom other procedures such as lysis of adhesion were necessary, the mean operative time increased to 278 minutes (193–463). In cases with additional required procedures, such as hiatal hernia repair, cholecystectomy, and Meckel diverticulum resection, operative time was calculated to be 272 minutes (range: 186–431) (Table 3). Operative time decreased progressively as experience increased (Fig. 2). The robotic time and laparoscopic time was not documented separately on the operative room sheets; however, the entire estimated docking and undocking time, including robotic positioning on the patient’s body, was approximately 15 minutes or less. No major intraoperative complications were experienced, and no operation was converted to an open procedure. Two patients had unplanned returns to the operating room: One patient had an inadvertently sutured nasogastric tube that was released endoscopically, and the other experienced a significant port site wound infection that turned into an abscess. She underwent laparoscopic exploration, formal wound exploration, and incision and drainage of the abscess. The length of hospital stay ranged from 1–13 Table 2 Preoperative co-morbidities Preoperative co-morbidities
Prevalence, %
Diabetes mellitus Hypertension Hyperlipidemia Obstructive sleep apnea Back pain Osteoarthritis Gastroesophageal reflux disease Hepatic steatosis Asthma Pseudotumor cerebri Depression Stress urinary incontinence
34 49 39 84 22 79 53 2 6 o1 26 14
Mean operative time, min Typical BPD-DS BPD-DS with adhesiolysis BPD-DS with other procedure Complications Anastomosis leak Hemorrhage Intraluminal Extraluminal Subcutaneous Intestinal obstruction Injury to other organs Venous thromboembolism (DVT, PE) Inadvertently sutured nasogastric tube Port site infection Other* Median length of stay (d) 30-d hospital readmissions Epigastric pain (required pain medication adjustment) Fluid retention (required aggressive diuresis) Incarcerated ventral hernia (required hernia repair procedure) Gastrointestinal bleeding (required blood transfusion) DVT/PE (required full anticoagulation)
249 (162–413) 278 (193–463) 272 (186–431) 0 1 0 0 0 0 1 1 1 1 2.7 (1–13) 1 1 1 1 1
Abbreviations: BPD-DS ¼ biliopancreatic diversion with duodenal switch; DVT ¼ deep vein thrombosis; PE ¼ pulmonary embolism. * Carpal tunnel syndrome exacerbation.
days with a median stay of 2.7 days. Two patients had significantly longer hospital stays. One was caused by worsening preexisting carpal tunnel syndrome that lasted 9 days and resolved spontaneously. Another patient had a prolonged hospital stay of 13 days as a result of incision and drainage port site wound and daily packing. Five patients were readmitted within 30 days after discharge from the hospital. One patient presented with fluid retention, which resulted in lower extremity edema and shortness of breath. One patient presented with preexisting incarcerated ventral hernia that was not repaired at the first procedure. One patient experienced lower gastrointestinal bleeding after swallowing an orange, whole, shortly after the procedure and presumably overstretched or traumatized her VSG staple line. This complication was resolved with blood transfusion and conservative management. One patient had significant epigastric pain and nausea of unknown origin, which was cured by intravenous fluid and analgesics. One patient presented with deep vein thrombosis and pulmonary embolism and was treated at a different facility with full anticoagulation (Table 3). Postoperatively, 100% of patients at 9 months, 71% of patients at 1 year, 45% of patients at 2 years, and 15% of patients at 5 years returned to the office for follow-up visits. In 1-, 3-, 6-, 9-, 12-, 18-, 24-, and 36-month follow-ups, patients experienced 19%, 35.9%, 53.1%, 65.5%, 74.6%,
370
G. Antanavicius et al. / Surgery for Obesity and Related Diseases 11 (2015) 367–371
Fig. 2. Operative time.
79.9%, and 75.8% excess weight loss, respectively. In postoperative follow-up, remission was defined as complete disappearance of co-morbidity, such as DM, according to the preoperative parameters with discontinuation of medications, and improvement was defined as persistence of the diseases according to the parameters, although with lesser amount or lower dosage of medications; 95.5% of diabetic patients had remission, and 4.6% experienced improvement. Patients with preoperative associated hypertension had 92.1% remission and 7.9% improvement. Individuals with hyperlipidemia had 92% remission, 5% improvement, and 3% no change in follow-up. No BPD-DS–related mortality occurred in this study up to 36 months after the procedure. Discussion The excellent outcome and maintenance of long-term weight loss, as well as correction of obesity-related comorbidities after BPD-DS, are well defined in the literature [2,7,8]. In a meta-analysis of weight loss surgery data, Buchwald et al. reported that BPD-DS provides the best long-term weight loss maintenance (70.1%) and complete or near complete resolution of DM (98%) with a mortality rate of 1.1% [9]. Other studies by Fazylov et al., Ren et al., and Spyropoulos et al. have reported a significant mortality rate to a maximum of 12.5%, especially in super morbidly obese patients (BMI 450 kg/m2) [10–12]. Technical challenges, especially constructing duodenoileal anastomoses, likely play a significant role in morbidity and mortality rates. Different techniques have been used to minimize the challenge. Weiner et al. reported 3 different laparoscopic techniques in creating duodenoileal anastomoses in a total of 63 patients [16]. These techniques included using a 21mm circular stapler, a side-to-side linear stapler to create posterior wall, a running hand-sewn Vicryl stitch to make anterior wall, and a complete hand-sewn anastomosis by
using 2-0 polypropylene stitch. One of 21 patients in the circular stapler group experienced an anastomosis leak and 3 others developed an abdominal wound infection at the side of circular stapler insertion. It was concluded that combined side-to-side linear stapling and hand-sewn anastomosis was the most well-tolerated technique with a comparable operative room time. Sudan et al. reported the first series of robotic BPD-DS in 2000 and described 4 anastomosis leaks without mortality in 47 patients. The incidence of leak was thought to be related to a lack of adequate surgeon experience and a high learning curve for this very complex procedure. The learning curve was estimated to be around 50 cases, at which point the complication rate tended to plateau. In a recent report of 80 patients who underwent robotic BPD-DS by Sudan et al., the operative duration decreased by an average of 3 minutes with each successive case (P o .001, R² ¼ .63). The incidence of high blood loss (13.3%), conversion (2.2%), and leaks (5.8%) were experienced by a total of 22 patients (18.3%) [13–15]. In the present series, the robot system was used in constructing duodenoileal anastomosis in a similar manner as described by Sudan et al. The robotic approach offers superior visualization of the duodenal stump and allows for the ability to have 180-degree wrist rotation and precision to perform hand-sewn anastomosis. Other benefits, such as 3dimensional vision, minimization of tremor, and elimination of image reversal, aid in creating a better technical approach for performing the anastomosis. Robotic arms prevent transmission of tissue toque related to abdominal wall thickness and provide precision throughout the procedure. Although mastery of the laparoscopic suturing technique is beneficial, the authors believe that the robotic system may offer some advantage in perfecting duodenoileal anastomosis. In the present series, no technical complications were experienced, especially leaks related to duodenoileal anastomosis. A disadvantage of this technique includes the potential cost and time for using robotic system, which arguably can be
One-Stage Operation with Robotic Assistance / Surgery for Obesity and Related Diseases 11 (2015) 367–371
minimized in high-volume centers. The other disadvantage is the absence of tactile feedback. More studies and data analysis will be needed, but it is likely that new, cheaper robotic systems will ultimately become widely adopted. Conclusions Robotic assistance is useful in performing BPD-DS. It is a well-tolerated and potentially useful tool that offers the benefits of good visualization, more precise maneuverability, elimination of tremor, ability to adapt to patients’ technical limitations, and image reversal during performance of hand-sewn anastomosis. Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article. References [1] Mechanick JI, Kushner RF, Sugerman HJ, et al. American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guideline for Clinical Practice for the preoperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient. Surg Obes Relat Dis 2008;4(Suppl 5):S84–109. [2] Duckworth W, Abraira C, Moritz T, et al. Glucose control and vascular complications in veterans with type 2 diabetes. N Engl J Med 2009;360:129–39. [3] Buchwald H, Estok R, Fahrbach K, Banel D, Sledge I. Trends in mortality in bariatric surgery: a systematic review and meta-analysis. Surgery 2007;142:621–32. [4] Kim WW, Gagner M, Kini S, et al. Laparoscopic vs. open biliopancreatic diversion with duodenal switch: a comparative study. J Gastrointest Surg 2003;4:552–7.
371
[5] Topart P, Becouarn G, Ritz P. Should biliopancreatic diversion with duodenal switch be done as single-stage procedure in patients with BMI Z50 kg/m2? Surg Obes Relat Dis 2010;6:59–63. [6] Cottam D, Qureshi FG, Mattar SG, et al. Laparoscopic sleeve gastrectomy as an initial weight-loss procedure for high-risk patients with morbid obesity. Surg Endosc 2006;20:859–63. [7] Parikh MS, Shen R, Weiner M, Siegel N, Ren CJ. Laparoscopic bariatric surgery in super-obese patients (BMI 450) is safe and effective: a review of 332 patients. Obes Surg 2005;15: 858–63. [8] Stephens DJ, Saunders JK, Belsley S, et al. Short-term outcomes for super-super obese (BMI Z60 kg/m2) patients undergoing weight loss surgery at a high-volume bariatric surgery center: laparoscopic adjustable gastric banding, laparoscopic gastric bypass, and open tubular gastric bypass. Surg Obes Relat Dis 2008;4:408–15. [9] Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA 2004;292:1724–37. [10] Ren CJ, Patterson E, Gagner M. Early results of laparoscopic biliopancreatic diversion with duodenal switch: a case series of 40 consecutive patients. Obes Surg 2000;10:514–23. [11] Fazylov RM, Savel RH, Horovitz JH, et al. Association of supersuper-obesity and male gender with elevated mortality in patients undergoing the duodenal switch procedure. Obes Surg 2005;15: 618–23. [12] Spyropoulos C, Bakellas G, Skroubis G, et al. A prospective evaluation of a variant of biliopancreatic diversion with Roux-en-Y reconstruction in mega-obese patients (BMI Z70 kg/m2). Obes Surg 2008;18:803–9. [13] Sudan R, Puri V, Sudan D. Robotically assisted biliary pancreatic diversion with a duodenal switch: a new technique. Surg Endosc 2007;21:729–33. [14] Sudan R, Bennett KM, Jacobs DO, Sudan DL. Multifactorial analysis of the learning curve for robot-assisted laparoscopic biliopancreatic diversion with duodenal switch. Ann Surg 2012;255:940–5. [15] Buchs NC, Pugin F, Bucher P, et al. Learning curve for robot-assisted Roux-en-Y gastric bypass. Surg Endosc 2012;4:1116–21. [16] Weiner RA, Blanco-Engert R, Weiner S, Pomhoff I, Schramm M. Laparoscopic biliopancreatic diversion with duodenal switch: three different duodeno-ileal anastomotic techniques and initial experience. Obes Surg 2004;3:334–40.