Although laparoscopic Roux-en-Y gastric bypass (LRYGB) is a common bariatric procedure worldwide, no consensus on the optimal technique for the gastrojejunostomy (GJ) has been reached. Circular ...stapling (CS) immediately results in a GJ of standardized width, whereas linear stapling (LS) requires a technically challenging closure of the stapler defect. The aim was to study differences in outcomes between CS and LS.
Nationwide Swedish cohort.
The Scandinavian Obesity Registry (SOReg) included prospective data from 34,284 primary LRYGB patients operated on in 2007-2013. We studied operative time, length of hospital stay, postoperative complications, and percent excess body mass index loss (%EBMIL) after 1 year. Outcomes were assessed through multivariate analysis adjusting for gender, age, preoperative body mass index (BMI), and diabetes.
Preoperatively the groups were similar (40.9 yr, BMI 42.4 kg/m(2), 76% female). For CS and LS, operative time and hospital stay were 114 and 73 minutes (P<.001) and 4.6 and 2.0 days (P<.001), respectively. Using LS as a reference, adjusted odds ratio (OR) for CS patients to have anastomotic leakage was 2.8 (95% CI 1.5-5.0), postoperative hemorrhage 1.9 (95% CI 1.2-2.9), wound complication 9.7 (95% CI 6.8-13.9), and marginal ulcer 3.1 (95% CI 1.8-5.3). The %EBMIL at 1 year was 80% for both techniques and 31% of total weight was lost. Follow-up rate at 6 weeks and 1 year was 96% and 73%, respectively.
CS was found to be associated with disadvantages regarding operative time, hospital stay, and postoperative complications compared with LS.
To compare circular stapler (CS) with linear stapler (LS) in a meta-analysis concerning operative time, anastomotic leaks, wound infections, strictures, and length of stay. Pubmed, Medline, and ...Scopus were searched for articles published since 2006. Four hundred and five articles were assessed, and 13 articles of which only one was a randomized controlled trial were included in all 49,331 patients from different regions of the world. The pooled analysis shows that operative time was shorter in LS than in CS (weighted mean difference 36.2 min; 95% CI 34.7–37.6.;
p
< 0.0001). No difference was seen concerning leaks or strictures. The relative risk (RR) of leakage after LS was 80% of the risk after CS; however, the 95% confidence interval (CI) showed overlap (0.58–1.11). The RR of anastomotic stricture after LS was 74% of the risk after CS; however, 95% CI (0.52–1.05) showed overlap. Wound infections were less common after LS than after CS; RR was 27% (95% CI 0.21–0.33). Length of stay (LOS) was 0.65 days shorter after LS than after CS (95% CI 0.51–0.78). LS compared with CS results in shorter operative time, less wound infections, and shorter length of stay, but no difference was seen concerning risks of leaks or strictures.
Background
Laparoscopic gastrectomy is increasingly used for the treatment of locally advanced gastric cancer but concerns remain whether similar results can be obtained compared to open gastrectomy, ...especially in Western populations. This study compared the short-term postoperative, oncological and survival outcomes following laparoscopic versus open gastrectomy based on data from the Swedish National Register for Esophageal and Gastric Cancer.
Methods
Patients who underwent surgery with curative intent for adenocarcinoma of the stomach or gastroesophageal junction Siewert type III from 2015 to 2020 were identified, and 622 patients with cT2-4aN0-3M0 tumors were included. The impact of surgical approach on short-term outcomes was assessed using multivariable logistic regression. Long-term survival was compared using multivariable Cox regression.
Results
In total, 350 patients underwent open and 272 laparoscopic gastrectomy, of which 12.9% were converted to open surgery. The groups were similar regarding distribution of clinical disease stage (27.6% stage I, 46.0% stage II, and 26.4% stage III). Neoadjuvant chemotherapy was administered to 52.7% of the patients. There was no difference in the rate of postoperative complications, but laparoscopic approach was associated with lower 90 day mortality (1.8 vs 4.9%,
p
= 0.043). The median number of resected lymph nodes was higher after laparoscopic surgery (32 vs 26,
p
< 0.001), while no difference was found in the rate of tumor-free resection margins. Better overall survival was observed after laparoscopic gastrectomy (HR 0.63,
p
< 0.001).
Conclusions
Laparoscopic gastrectomy can be safely preformed for advanced gastric cancer and is associated with improved overall survival compared to open surgery.
Roux-en-Y gastric bypass surgery (RYGB) as treatment of morbid obesity results in substantial weight loss. Most published long-term studies have included few patients at the last follow-up point. The ...aim of the present study was to explore long-term results in a large cohort of patients 7-17 years after gastric bypass.
All 539 patients who had undergone primary RYGB from 1993 to 2003 at Uppsala and Örebro University Hospitals received a questionnaire regarding their postoperative status. Blood samples were obtained and the medical charts studied.
Of the 539 patients, 384 responded (71.2% response rate, mean age 37.9 yr, body mass index 44.5 kg/m(2) at surgery, 317 women, and 67 men). At a mean follow-up of 11.4 years (range 7-17), the body mass index had decreased to 32.5 kg/m(2), corresponding to an excess body mass index loss of 63.3%. Similar weight loss was observed, regardless of the length of follow-up. Orally treated diabetes resolved in 72% and sleep apnea and hyperlipidemia were improved. Revisional bariatric surgery had been performed in 2.1% and abdominoplasty in 40.2%. The gastrointestinal symptoms were considered tolerable. The overall result was satisfactory for 79% of the patients and 92% would recommend Roux-en-Y gastric bypass to a friend. Attendance to the annual checkups was 37%. Vitamin B12 supplements were taken by 72% and multivitamins by 24%.
At 11 years, substantial weight loss was maintained and revisional surgery was rare. Surprisingly few patients were compliant with the recommendation of lifelong supplements and yearly evaluations; however, patient satisfaction was high.
Background
The aim of this study was to explore changes in liver volume and intrahepatic fat in morbidly obese patients during 4 weeks of low-calorie diet (LCD) before surgery and to investigate if ...these changes would facilitate the following laparoscopic gastric bypass.
Methods
Fifteen female patients (121.3 kg, BMI 42.9) were treated preoperatively in an open study with LCD (800–1,100 kcal/day) during 4 weeks. Liver volume and fat content were assessed by magnetic resonance imaging and spectroscopy before and after the LCD treatment.
Results
Liver appearance and the complexity of the surgery were scored at the operation. Eighteen control patients (114.4 kg, BMI 40.8), without LCD were scored similarly. Average weight loss in the LCD group was 7.5 kg, giving a mean weight of 113.9 kg at surgery. Liver volume decreased by 12% (
p
< 0.001) and intrahepatic fat by 40% (
p
< 0.001). According to the preoperative scoring, the size of the left liver lobe, sharpness of the liver edge, and exposure of the hiatal region were improved in the LCD group compared to the controls (all
p
< 0.05).
Conclusions
The overall complexity of the surgery was perceived lower in the LCD group (
p
< 0.05), due to improved exposure and reduced psychological stress (both
p
< 0.05). Four weeks of preoperative LCD resulted in a significant decrease in liver volume and intrahepatic fat content, and facilitated the subsequent laparoscopic gastric bypass as scored by the surgeon.
Roux-en-Y gastric bypass (RYGB) is the most common bariatric procedure worldwide. There are few studies investigating how early return to solid food affects complications.
The aim of this study was ...to explore how oral intake was resumed in RYGB patients and how the postoperative food regimen affects outcomes, such as complications and length of stay.
Retrospective nationwide registry study.
The Scandinavian Obesity Surgery Registry included prospective data from RYGB patients operated in 2009 to 2014. A questionnaire assessed the postoperative reintroduction of solid food applied at each bariatric center. The postoperative regimen was established in 23,589 patients. Outcomes were recorded at 30-day follow-up according to the standard Scandinavian Obesity Surgery Registry routine.
Nine percent of patients (n = 2074) returned to solid food within the first week after surgery. Most commonly solid food was resumed in week 4 (37%, n = 8659). Median length of stay was 2 days for all. Of all, 2.8% suffered from a severe complication (>Clavien-Dindo 3a). After adjusting for the annual volume of procedures at hospitals, there was no correlation that the timing of solid food affected complication rates. The odds ratio for a severe complication was significantly lower for intermediate- (odds ratio .64 95% confidence interval .48-.85) or high- (odds ratio .52 95% confidence interval .42-.66) volume centers. The rate of leaks and small bowel obstructions were evenly distributed between the different postoperative food regimens.
Early return to solid food after RYGB did not affect the risk of severe complications. Patients operated at centers with an annual volume of >100 procedures have a lower risk of severe complications.
Open Roux-en-Y gastric bypass (RYGB) may be chosen because of known widespread adhesions or as a result of conversion during laparoscopic surgery. Although conversions are rare, they occur even in ...experienced hands. The gastrojejunostomy may be performed with a circular stapler (CS) or a linear stapler (LS) or may be entirely hand sewn (HS). Our aim was to study differences in outcomes regarding the anastomotic techniques utilized in open surgery.
Nationwide cohort.
Data on open surgery, both primary open and converted procedures from Scandinavian Obesity Surgery Registry were analyzed for the years 2007-2013. Outcomes were assessed through multivariate analysis, adjusting for gender, age, preoperative body mass index, diabetes, conversion, and technique used for the gastrojejunostomy.
CS was the most common method used for primary open RYGB (58%), whereas LS was the most common for converted RYGB (63%). HS was uncommon in both groups. Operative time was shorter for LS than for CS in the primary open RYGB (110±40 min versus 132±46 min; P<.001). Anastomotic leakage rates were similar in primary open RYGB (1.0%-2.4%), but leakage rates for LS in converted procedures was 10.1%, thus higher compared with 2.1% in converted CS patients (P = .02). Odds ratio for leakage was 2.87 (95% confidence interval 1.18-6.97) for LS using CS as a reference when adjusting for variables above.
LS was associated to increased risk of leakage in patients with conversion from laparoscopic RYGB to open RYGB. Conversion to open surgery was associated to increased risk of leakage. Technique used for the gastrojejunostomy did not affect weight loss.
Weight loss before laparoscopic Roux-en-Y gastric bypass (LRYGB) is desirable, because it can reduce liver volume and thereby facilitate the procedure. The optimal duration of a low-calorie diet ...(LCD) has not been established. The objective of this study was to assess changes in liver volume and body composition during 4 weeks of LCD.
Ten women (aged 43±8.9 years, 114±12.1 kg, and body mass index 42±2.6 kg/m(2)) were examined on days 0, 3, 7, 14, and 28 after commencing the LCD. At each evaluation, body composition was assessed through bioelectric impedance analysis, and liver volume and intrahepatic fat content were assessed by magnetic resonance imaging. Serum and urine samples were obtained. Questionnaires regarding quality of life and LCD-related symptoms were administered.
In total, mean weight decreased by 7.4±1.2 kg (range 5.7-9.1 kg), and 71% of the weight loss consisted of fat mass according to bioelectric impedance analysis. From day 0 to day 3, the weight loss (2.0 kg) consisted mainly of water. Liver volume decreased by 18%±6.2%, from 2.1 to 1.7 liters (P<.01), during the first 2 weeks with no further change thereafter. A continuous 51%±16% decrease was seen in intrahepatic fat content. Systolic blood pressure, insulin, and lipids improved, while liver enzymes, glucose levels, and quality of life were unaffected.
A significant decrease in liver volume (18%) occurred during the first 2 weeks of LCD treatment, and intrahepatic fat gradually decreased throughout the study period. A preoperative 2-week LCD treatment seems sufficient in similar patients.
