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Laparoscopic Roux-En-Y Gastric Bypass Results and Learning Curve of a High-Volume Academic Program

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Laparoscopic Roux-En-Y Gastric Bypass Results and Learning Curve of a High-Volume Academic Program PAPER Laparoscopic Roux-en-Y Gastric Bypass Results and Learning Curve of a High-Volume Academic Program Scott A. Shikora, MD; Julie J. Kim, MD; Michael E. Tarnoff, MD; Elizabeth Raskin, MD; Rebecca Shore, MD Hypothesis: Laparoscopic Roux-en-Y gastric bypass is mortality was 0.3%. For the first 100 cases, the overall a complex procedure performed on a high-risk patient complication rate was 26% with a mortality of 1%. This population. Good results can be attained with experi- complication rate decreased to approximately 13% and ence and volume. was stable for the next 650 patients. The incidence of ma- jor complications has also decreased since the first 100 Design: Retrospective study. cases. Leak decreased from 3% to 1.1%. Small-bowel ob- struction decreased from 5% to 1.1%. Overall mean op- Setting: Tertiary care academic hospital. erating time was 138 minutes (range, 65-310 minutes). It decreased from 212 minutes for the first 100 cases to Patients: Seven hundred fifty consecutive morbidly obese 132 minutes for the next 650 and 105 minutes (range, patients undergoing surgery from March 1998 to April 65-200 minutes) for the last 100 cases. 2004. Conclusions: Laparoscopic Roux-en-Y gastric bypass is Interventions: All patients underwent laparoscopic a technically difficult operation. This review of a large Roux-en-Y gastric bypass. series in a high-volume program demonstrated that the Main Outcome Measures: Perioperative deaths and morbidity and mortality could be reduced by 50% with complications. experience. The results are similar to those reported from other major centers. In addition, as reported elsewhere, Results: The patient population was 85% women and the learning curve for this procedure may be 100 cases. had a mean body mass index of 47 kg/m2 (range, 32-86 kg/m2). The overall complication rate was 15% and the Arch Surg. 2005;140:362-367 VER THE PAST 20 YEARS, tions for achieving meaningful and sus- the United States and the tainable weight loss.3 Mirroring the rise in world at large have seen prevalence of obesity has been the dra- a staggering increase in matic increase in the number of bariatric the prevalence of obe- procedures performed. In fact, the num- Osity. Recent surveys by the Centers for Dis- ber of procedures performed yearly in the ease Control and Prevention (Atlanta, Ga) United States has increased a staggering suggest that more than 64% of US adults 644% in the last decade.4 This increase can are overweight and 5% are morbidly obese, be attributed to the increased public aware- defined as having a body mass index (BMI) ness of the health risk associations of obe- greater than or equal to 40 kg/m2.1 Obe- sity and its staggering societal cost and the sity is associated with health-affecting greater acceptance of surgery as a legiti- comorbidities such as diabetes mellitus, mate treatment. Equally significant is the hyperlipidemia, hypertension, and ob- adaptation of minimally invasive tech- structive sleep apnea. These adverse con- niques to the field of bariatric surgery. ditions contribute to the increased risk for Laparoscopic and minimally invasive premature death and disability for per- surgery have now extended into almost all sons with BMIs greater than 25.2 Com- surgical disciplines. The benefits of de- Author Affiliations: Division of monly refractory to conservative weight creased postoperative pain, length of hos- Bariatric Surgery, Department of loss treatments, morbid obesity has be- pital stay, wound morbidity, and even im- Surgery, Tufts-New England come a surgical disease. Operations to treat proved cosmesis are particularly appealing Medical Center, Boston, Mass. obesity are the most effective interven- for this complex patient population. (REPRINTED) ARCH SURG/ VOL 140, APR 2005 WWW.ARCHSURG.COM 362 ©2005 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/28/2021 Roux-en-Y gastric bypass (RYGBP) is currently the pro- 400 cedure of choice in the United States for intractable mor- Other 5 350 bid obesity. However, it has traditionally been a formi- Open RYGBP dable operative procedure with the potential for 300 LRYGBP catastrophic complications. In 1994, Wittgrove and Clark6 250 described the first successful laparoscopic gastric bypass 200 150 procedure. Since that time, the number of laparoscopic gas- No. of Cases tric bypass procedures has increased dramatically as the 200 equipment has improved and surgeons across the coun- 50 try have undergone extensive training. However, the lapa- 0 roscopic Roux-en-Y gastric bypass (LRYGBP) remains a 1 2 3 4 5 6 more technically challenging operation compared with its Year open counterpart. Some surgeons have reported that the Figure. Overall bariatric case volume at Tufts-New England Medical Center 7,8 learning curve is approximately 75 to 100 cases. In ad- from March 1998 to April 2004. During that period, there has been a sharp dition, other studies have suggested that the operative mor- increase in total cases and the number of laparoscopic Roux-en-Y gastric bidity and mortality were somewhat dependent on case bypass (LRYGBP) procedures performed. The number of open Roux-en-Y 9-11 gastric bypass (RYGBP) procedures performed annually decreased volume. The purpose of this study was to evaluate the dramatically as the LRYGBP became more routinely offered. Other bariatric role of technical experience and patient volume in reduc- procedures refer to laparoscopic adjustable gastric bands and revisional ing the rate of perioperative and postoperative complica- procedures. tions in patients who underwent LRYGBP. kg/m2. The Roux limb was brought retrocolic and retrogastric. METHODS The gastrojejunostomy was created using the 25-mm CEEA (cir- cular end-to-end anastomosis) stapler (US Surgical Corp) with the stapler’s anvil placed into the pouch via a transabdominal To be considered for surgery, all patients had to satisfy the cri- technique. The pouch’s staple line and the gastrojejunostomy teria for gastric bypass surgery as stated in the 1991 National were checked for leakage by inflating the pouch and proximal Institutes of Health Consensus Development Conference State- Roux limb with2Lofoxygen and flooding the left upper quad- ment on obesity.12 All patients also had to successfully com- rant of the abdomen with saline. Bubbling observed in the sa- plete the interdisciplinary screening and preparatory process line pool would identify a leak. This would then be corrected for bariatric surgery by the various health care professionals with sutures until normal air test results were achieved. A closed of the Obesity Consult Center of Tufts-New England Medical suction drain was placed between the staple lines of the pouch Center in Boston, Mass. and excluded stomach in all patients. We have maintained a prospective database for all patients The jejunojejunostomy was created in a side-side fashion undergoing LRYGBP at Tufts-New England Medical Center since between the biliopancreatic limb and the Roux limb. The Endo March 1998. Baseline patient characteristics, including age, sex, GIA linear cutting stapler with a 60-mm long, 2.5-mm car- height, weight, BMI, percentage excess weight, and comorbid con- tridge was passed distally into each limb of bowel through small ditions, were recorded in the program’s bariatric database. At the enterotomies created on the antimesenteric borders. After fir- time of surgery, operating time, blood loss, length of stay, and ing the stapler, it was reintroduced with a 30-mm long, 2.5-mm operative complications were recorded. Following surgery, pa- cartridge proximally through the now common enterotomy. Af- tients were monitored for complications including signs of staple- ter firing, the common enterotomy was closed transversely with line leak (signs of peritonitis or abnormal output from the drain), a 60-mm long, 2.5-mm cartridge. The mesenteric defect was hemorrhage, obstruction, and infections. After hospital dis- closed initially with interrupted silk sutures (first 440 cases) charge, all patients were followed up as per the protocol for sur- but has since been closed with running silk suture. At the con- gical follow-up established by the Obesity Consult Center. Al- clusion of the gastric bypass, the internal hernia spaces were though postoperative radiographic or endoscopic studies were closed. The Petersen space was obliterated by tacking the proxi- not routinely performed, there was a low threshold to study any mal Roux and biliopancreatic limbs together. The mesocolic patient who returned for a follow-up appointment with any gas- defect was controlled by tacking the Roux limb to the cut edges trointestinal symptoms such as pain, vomiting, or inadequate of the mesocolon. Twelve-millimeter port wounds were closed weight loss. at the level of the fascia, and all port sites were closed with sub- For this investigation, a retrospective analysis was per- cuticular running suture. formed on the database of the first 750 consecutive morbidly obese patients undergoing LRYGBP from March 1998 to April 2004. Operative time, blood loss, length of hospitalization, and RESULTS 30-day morbidity and mortality were analyzed. The data were analyzed after segregation into 5 different categories based on From March 1998 to April 2004, 750 patients under- chronology: the first 100 cases (1-100), the second 100 cases went LRYGBP at Tufts-New England Medical Center. The (101-200), all cases after the first 100 cases (101-750), the last patients were predominantly female (85%) with a mean 100 cases (651-750), and all cases (1-750). age of 41 years (range, 14-69 years). Body mass index Except for some minor alterations, all patients underwent spanned the range of 32 kg/m2 to 86 kg/m2, with an av- LRYGBP performed in a similar fashion. The gastric pouch was erage BMI of 47 kg/m2 and a median BMI of 46 kg/m2.
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