Laparoscopic Articles from Laparoscopy Hospital

Dr. Danish Javed, M.S.
General surgeon., Haridwar,Uttarakhand,( India )

INTRODUCTION:

Obesity is the commonest form of malnutrition and it has been increasing over the last few decades globally [1-3]. In India up to 50% of women and 32.2% of men in the upper socio-economic class comes under the obese category. In Delhi the prevalence of obesity is 33.4% in women and 21.3% in men [4-5]. According to Framingham data for each pound weight gained between ages 30 to 42 years, there is 1% increased mortality within 26 years, and for each pound gained after that, it is the 2% increased mortality. In morbid obese, average life expectancy is reduced by 12 years in men and 9 years in women [6]. Type II diabetes, hypertension, hyper-lipidemia, stroke, atherosclerosis, osteo-arthritis, hypoventilation, sleep apnea syndrome, GERD, infertility and urinary stress incontinence in females, certain cancers(endometrium, colon, breast, prostate) and sudden death are co-morbidities [7]. Surgical management of morbid obesity is increasing in response to its epidemic rise [8]. Between 1998 and 2002, there was a 450% increase in the number of bariatric operations performed in the United States , a 144% increase in the number of American Society for Bariatric Surgery bariatric surgeons, and a 146% increase in the number of bariatric centers. The growth of laparoscopic bariatric surgery during this 5-year period greatly exceeds that of open bariatric surgery [9]. National Institutes of Health Consensus (NIH) Conference convened in 1991, specifically identified Roux-en- Y gastric bypass (RGB) and vertical banded gastroplasty (VBG) as surgical options that provide significant benefits for patients with clinical severe obesity. In 1994, Wittgrove, Clark, and Tremblay performed the first laparoscopic RYGB (LRYGB), which at the time was considered a technical tour de force [10] .

There are following different options available in bariatric surgery [11].

AIM:

The aim of this study is to review the various aspect of the laparoscopic Roux-en-Y Gastric Bypass to emphasize its significance in Bariatric Surgery.

Materials and Methods:

A thorough literature and clinical search was performed by using search engines Google, HighWire Press, Springer Link etc .The following search terms was used: morbid obesity, laparoscopy Bariatric Surgery, Roux-en-Y, Comparison obesity surgery, open laparoscopy bariatric, complication Roux-en-Y .

History:

In 1954, Kremen et al performed the first intestinal bypass via jejuno-ileostomy, and in 1956, Payne and DeWind performed a distal jejunocolonic anastomosis. Later it was modified by Sherman et al, who sutured 14 inches of proximal jejunum end-to-side to the terminal ileum,4 inches proximal to the ileo-cecal valve. Mason and Ito devised a gastric bypass procedure for morbid obesity in1966, after noting the weight reduction in gastric resection for gastric ulcer. Initially, they transected the stomach horizontally and performed a loop gastro-jejunostomy to the proximal portion of the stomach. Over several decades, the gastric bypass has been modified into its current form, using a Roux-en-Y limb of intestine (RYGBP).In 1994, Wittgrove, Clark , and Tremblay reported the first case series of laparoscopic RYGBP [10].

Surgical Technique:

In LRYGBP procedure, six small incisions are made, through which ports are inserted for abdominal access. Dissection is started at the fundus of stomach with division of phrenico-gastric ligament. The stomach is divided with laparoscopic straight four row cutting 60 mm stapler to create a 15-20cc pouch. The ligament of Treitz is identified initially, and the proximal jejunum is divided approximately 50 cm distal to this point. A gastro-jejunostomy is performed either hand sutured, linear staplers or by circular staplers. A jejuno-jejunostomy is performed with laparoscopic staplers. A Roux limb of between 75 to 200 cm is formed depending on the BMI, and the jejuno-jejunal mesenteric defect is closed to avoid postoperative internal hernias. The Roux limb is placed in an ante-colic fashion. The anastomosis is tested by gastroscopy for evidence of any leak after the procedure.

Comparison of LRYGBP with other methods of laparoscopic bariatric surgery:

Laparoscopic Roux-en- Y gastric bypass is, in reality, a well-structured and well-understood operation that is valuable for the treatment of clinical severe obesity. Longer follow-up evaluation and experience with Vertical Banded Gastroplasty shows that patients frequently changes dietary habits postoperatively, ingests high-calorie soft foods and liquids, and regains weight [12]. Because of these long-term results, the operation has been largely abandoned.

A Prospective, Comparative Analysis performed by Wilbur B. Bowne et al(2006), has shown the laparoscopic Gastric Bypass is superior to Adjustable Gastric Band in super morbidly obese patients. The patients who underwent Laparoscopic Adjustable Gastric Banding (LAGB) experienced a greater incidence of late complications ( P <0.05), re-operations ( P <0.04), less weight loss ( P <0.001), and decreased overall satisfaction ( P <0.006). Likewise, patients who underwent LRYGB had a greater resolution of concomitant diabetes mellitus ( P <0.05) and sleep apnea ( P <0.01) compared with the LAGB group. Furthermore, postoperative adjustments to achieve consistent weight loss for LAGB recipients ranged from 1 to 15 manipulations. Single mortality was also in this LAGB group [13]. In one another study, LAGB is found significantly associated with more late complications, re-operations, less weight loss, less reduction of medical co-morbidity, and patient dissatisfaction compared with LRYGB [14].

The following table shows the outcome of different types of bariatric operations .

Table 1 . Outcomes of laparoscopic bariatric operations:

VBG, vertical banded gastroplasty; RYGB, Roux-en-Y gastric bypass;BPD, biliopancreatic diversion; DS, duodenal switch; LOS, length of hospital stay Source: [15] a: Data for laparoscopic BPD and DS are few, and these are based largely on available data for open procedures.

RYGBP is safe as well as effective procedure:

The laparoscopic Roux-en-Y gastric bypass has been shown to be safe and effective for the non super-obese patient (BMI <50) by Wittgrove et al [16]. Using same techniques, Nguyen et al were able to perform RYGBP on a patient with a BMI of 61 [17]. Kelvin D. Higa et al (2000) studied a case series of 400 morbidly obese and super-obese individuals who underwent the laparoscopic Roux-en-Y gastric bypass over a 22-month period. They observed that RYGBP can be safely and effectively performed in the community setting using advanced laparoscopic techniques [18].

Laparoscopic Roux-en-Y gastric bypass is a re-do procedure for failed restrictive gastric surgery:

Conclusion Based on the various text, it can be assume that restrictive surgery for morbidly obesity will certainly require many re-operations in the future. The standard operation of choice is LRYGBP. In a study conducted by Van Dessel et al (2006 ) , has shown this procedure a higher, but not significantly early morbidity rate when the indication for re-do surgery was a technical complication of the initial procedure [19].

Effect of Roux-en-Y gastric bypass on the level of serum Ghrelin:

Ghrelin, an acylated protein, is an orexigenic hormone, decreases after feeding and increases before meals, achieving concentrations sufficient to stimulate hunger and food intake. This hormone is basically produced from entero-endocrine cells of gastric mucosa and somewhat from the duodenum. RYGBP seems to achieve a very strong suppression of serum ghrelin level in contrast with gastric banding procedure. These findings are consistent with the assumption that by suppression of ghrelin, gastric bypass can reduce body weight in long term, more than gastric banding. Still, the mechanism by which gastric bypass leads to a reduction in ghrelin level, is not completely understood. It was advanced by the hypothesis that a permanent absence of food in stomach resulting from gastric bypass could cause an uninterrupted stimulatory signal that ultimately decreases ghrelin production by overriding inhibition [20].

RYGBP is the most effective treatment for Type 2 Diabetes Mellitus in morbidly obese patients:

Many studies clearly demonstrated that LRYGBP is highly effective in achieving excellent control in patients with T2DM.After six months of surgery, most patients easily withdraw there all anti-diabetic medications including insulin. Improvement in glucose metabolism occurs early after LRYGB and therefore is not entirely related to weight loss. A study by Alfonso et al (2005) suggests that central obesity negatively influences the likelihood of T2DM resolution after RYGB. They also suggests that RYGBP should be considered as standard treatment of T2DM in obese [21].A resent research paper of Luigi (2007)also says that bariatric surgery appears to be an effective and beneficial intervention in selected obese(BMI > 35 kg/m 2 ) patients with diabetes, when medical and nutritional approaches have failed to achieve the desired outcomes. This becomes especially true when metabolic control in these individuals has not been achieved despite aggressive medical therapy [22].

LRYGBP and effect of learning curve:

Studies conducted by Papasavas et al (2002) and C.Bal et al(2004) tells that it is a technically demanding procedure with significant morbidity during the learning curve. The learning curve soon overcomes, and reaches a rate plateau of complications after adequate training. The mean operating room time and the conversion rate improves with experience. Morbidly obese patients should be operated on in expert bariatric surgical laparoscopic units to obtain the best results [23-24].

Totally Robotic Roux-en-Y Gastric Bypass:

In 2003, Muhlmann et al. conducted a study to compare laparoscopic vs. robotic bariatric procedures. The robotic aided procedure proved to be 30% faster than were even experienced laparoscopic surgeons [25]. Catherine et al (2005) study details the report demonstrates the feasibility, safety, and potential superiority of such a procedure. They say that learning curve may also be significantly shorter with the robotic procedure [26].

COMPLICATIONS:

Complications can be of 2 types, early and late.

Early

1. Anastomotic leak

2. Pulmonary embolism

Late

1. Anastomotic stricture

2. Internal hernia

3. Dumping syndrome

4. Nutritional deficiencies

Comparison with open and laparoscopic RYGBP is associated with reduction in frequency of iatrogenic splenectomy, wound infection, incisional hernia, and mortality; however, there is an increase in the frequency of early and late intestinal obstruction, gastrointestinal tract bleed and stomal stenosis. There are no significant differences in the frequency of anastomotic leak, pulmonary embolism, or pneumonia [27]. Retrospective study of 400 consecutive RYGB patients ( from 1999-2002) supports that ,enteric leakage is an important complication of the RYGB. Leaks that are more insidious can be treated successfully with per-cutaneous drainage [28].Leak after LRYGB may be difficult to detect. Evidence of respiratory distress and tachycardia exceeding 120 beats per min may be the most useful clinical indicators of leak after laparoscopic Roux-en-Y gastric bypass [29].

E. Comeau et al (2003) documented 35 cases of internal hernia (overall incidence of 3.3 % ). The IH occurred in 6.0 % of patients with retro-colic procedures and 3.3 % of patients with ante-colic procedures. Most were in the Petersen defect (55.9 % ) and at the entero-enterostomy site (35.3 % ). A bimodal presentation was observed, with 22.9 % of patients with IH diagnosed in the early postoperative period (2–58 days) and 77.1 % in a delayed fashion (187–1,109 days). A laparoscopic approach to the repair of IH was possible in 60.0 % of patients. Complications occurred in 18.8 % of patients, including one death (2.9 % ) [30].

Figure 2. Sites of retroanastomotic or transmesenteric internal hernias, including mesocolic window or retrocolic tunnel ( green arrow ) mesenteric defect, Petersen’s mesenteric defect ( blue arrow ), and enteroenterostomy or distal anastomosis mesenteric defect ( red arrow ).

CONCLUSION:

The selection of surgical technique for a particular patient must be decided by a surgeon who has all of the tools accessible to him in his surroundings. Decisions should be made depending on the individual clinical scenario. No single tool or procedure can be

considered suitable for all patients. Assimilation of all the known data is essential for the surgeon to offer the correct procedure to the correct patient. The well-informed and well-trained individual will recognize that the best preference for most patients looking for surgical treatment of clinical severe obesity is laparoscopic RYGBP.

REFRENCES: