Laparoscopic Bariatric Surgery

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Surgery Laparoscopic Surgery
Laparoscopic Bariatric Surgery
a report by
A t u l K M a d a n , M D , FAC S
Chief, Section of Minimally Invasive Surgery, Associate Professor, Department of Surgery, University of Tennessee Health Science Center
Introduction
Bariatric surgery—weight loss surgery—has undergone an evolution over the
last decade. In 1991, the US National Institutes of Health (NIH) consensus
conference stated the surgery was the only consistent effective method of
long-term weight loss for the morbidly obese.1 In addition,
recommendations were made for whom surgery may be recommended (see
Table 1). Although these recommendations assisted in the acceptance of
bariatric surgery in the medical field, it was not until the growth of patient
demand, spawned by two major developments, that there was an
exponential growth of bariatric surgery.
Growth of Bariatric Surgery
One of the major developments was in 1994, when Wittgrove et al.
reported the first laparoscopic Roux-en-Y gastric bypass (LRYGB).2 While
certain potential complications (such as leak, pulmonary embolism, and
death) did not disappear, laparoscopy offered the appeal of smaller
incisions, less pain, and shorter recovery. Many surgeons were dubious of
this new approach, probably due to the learning curve of LRYGB, which
has been suggested to be at least 100 cases.3-6 The group at the University
of California, Davis, led by Ngyuen and Wolfe, performed a series of
randomized studies comparing LRYGB with the open approach, which
demonstrated the equivalent or superior results of LRYGB in most outcome
measures.7-13 The other major development in bariatric surgery was the
surge of media attention on the field. This surge was fueled by celebrities
(such as Carnie Wilson and Al Roker) who had undergone bariatric surgery.
In fact, the former displayed her physical results of LRYGB and cosmetic
surgery in Playboy. While her pictorial obviously did not add to (but did not
deter) the medical acceptance of bariatric surgery, this publicity contributed
to the large patient demand stirred by the spotlight of the media. Seeing
was believing for many. More recently, the literature in non-surgical journals
has demonstrated the superiority of bariatric surgery to medical treatment
for morbid obesity.14-16 Not only does weight loss occur after bariatric
surgery, but also comorbidities such as diabetes, hypertension, sleep apnea,
and hyperlipidemia all improve or resolve after bariatric surgery. While the
actual numbers vary depending on follow-up, particular procedure,
particular patient population, and study design, there is no doubt about the
medical benefit of bariatric surgery on a morbidly obese patient.
Laparoscopic Versus Open
Nguyen et al. performed a series of prospective, randomized studies
comparing LRYGB with open Roux-en-Y gastric bypass (ORYGB).7-13 These
studies basically demonstrated equivalent results in terms of weight loss.
However, LRYGB faired better in many aspects, such as pain and recovery.
Table 2 summarizes many of their results. Two other prospective,
© TOUCH BRIEFINGS 2007
randomized trials provided further data to support these conclusions.7,17,18
Types of Procedure
Weight loss after bariatric surgery occurs due to two main methods:
restriction and malabsorption. Restrictive procedures cause patients to
feel full after consuming smaller quantities (usually less than four
ounces). Malabsoprtive procedures cause a portion of the consumed
calories not to be absorbed.
Restrictive
The current major restrictive procedure is laparoscopic adjustable gastric
banding (LAGB). A band with a balloon is placed around the upper aspect
of the stomach. The balloon is attached to the port (which is placed on the
fascia of the anterior abdominal wall) via tubing. To adjust the band, fluid is
placed in the port and the balloon is inflated or deflated. Historically, the
vertical banding gastroplasty (VBG) has been performed. Unfortunately, due
to staple line disruption, failures were often seen after VBG. In addition, the
band placed in the VBG could become tight or loose. Loose bands would
result in loss of restriction, while tight bands could result in major
gastrointestinal symptoms. In addition, tight bands may cause patients to
tolerate only unhealthy foods (such as ice cream, liquids high in sugars,
etc.). LAGB offers an adjustability of the band, which removes the fear of a
too tight or too loose band. The lack of a staple line decreases the worry of
a staple line disruption or leak. Weight loss does occur more slowly than
other procedures; however, the peri-operative morbidity and mortality is the
lowest of all procedures. The surgical technique and follow-up of patients
determines the overall weight loss and long-term complications.
Malabsorptive
Malabsorptive procedures involve re-routing the small bowel to cause the
ingested food to bypass (or avoid) part of the small bowel, thus reducing the
amount of absorption that occurs. The most commonly performed procedure
is a biliopancreatic diversion (BPD) with or without a duodenal switch (DS)
when the stomach is reduced in size to some degree but mainly a large part
Atul Madan, MD, FACS, is Associate Professor of Surgery and Chief of the Minimally Invasive
Surgery section at the University of Tennessee Health Science Center. He is also Co-Director of the
Bariatric Program at UT Medical Group, Inc. A board-certified surgeon who specializes in bariatric
surgery for obese patients and other laparoscopic surgical procedures, he performed the Memphis
area’s first laparoscopic gastric bypass in 2002. He is the recipient of many honors, including the
American Medical Association Physician's Recognition Award. He has authored or co-authored
over 150 medical articles, book chapters, abstracts, and presentations, both nationally and
internationally, on such topics as gastrointestinal and laparoscopic surgery, breast cancer
screening and surgical treatment, and hiatal hernia repair.
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Table 1: NIH Consensus Recommendations for Morbid Obesity
BMI >40kg/m2 or BMI >35kg/m2, with an obesity-related comorbidity
Multiple failed medical attempts of weight loss
Appropriate pre-operative counseling and education
Appropriate long-term follow-up and care
BMI (body mass index) = weight (kg)/height2 (m2).
Table 2: Comparison of Laparoscopic Versus Open Gastric Bypass
Laparoscopic
Less pain
Fewer morphine requirements
Less segmental atelectasis
Less suppression of pulmonary function
Shorter hospital stay
Longer operation
Less blood loss
Higher operative costs
Lower hospital costs
Shorter overall recovery
Quicker improvement in quality of life
Less risk of infection
Fewer incisional hernias
Lower increase of norepinephrine, ACTH,
C-reactive protein, and IL-6 levels
Similar weight loss at three years
Open
More pain
More morphine requirements
More segmental atelectasis
More suppression of pulmonary function
Longer hospital stay
Shorter operation
More blood loss
Lower operative costs
Higher hospital costs
Longer overall recovery
Slower improvement in quality of life
Higher risk of infection
More incisional hernias
Higher increase of norepinephrine, ACTH,
C-reactive protein, and IL-6 levels
Similar weight loss at three years
ACTH = adrenocorticotropic hormone; IL = interleukin.
Table 3: Comparison of LAGB and LRYGB
LAGB
Less than one hour for procedure
Hospital stay—less than 1 day
Gastrointestinal tract not entered
Foreign body
Death—<0.1%
Leak—<0.1%
Slower weight loss
50–60% 5-year excess body-weight loss
Restrictive only
Reversible
Not a ‘magic pill’
Long-term worry of erosion, slippage,
infection of device
LRYGB
1–2 hours for procedure
Hospital stay—2 days
Gastrointestinal tract entered
No foreign body
Death—1%
Leak—1–2%
Faster weight loss
60–70% 5-year excess body-weight loss
Restrictive and malabsoprtive
Extremely difficult to reverse
Not a ‘magic pill’
No device worries
of the small bowel is bypassed. The main issue of the malabsorptive
procedures is the increased morbidity and mortality of the procedure. The
malabsorptive procedures also have issues concerning dehydration,
malnutrition, and vitamin deficiency. They may be gaining popularity in some
areas, but they still are not considered standard of care by many.
Combination of Restrictive and Malabsorptive
The most commonly performed procedure in the US is Roux-en-Y gastric
bypass (RYGB). LRYGB is the preferred technique, although some surgeons
have good results with the open technique. Either technique combines
restriction with malabsorption to provide weight loss. A small pouch is
made from the upper stomach. The food travels down the Roux limb to
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meet the biliopancreatic limb to form the common channel where most
absorption will take place. In theory, the longer the Roux limb, the more
malabsorption. RYGB can also cause dumping syndrome, which hopefully
will result in a subconscious negative feedback against foods with a high
concentration of sugars.
Comparison of LRYGB and LAGB
Since worldwide the two most common procedures are RYGB and LAGB, a
comparison of these two procedures is helpful when discussing options
with patients. Table 2 demonstrates a simplified version of comparison that
the authors discuss with all patients prior to any bariatric prodecure.19-21
Centers of Excellence
The growth of bariatric surgery has resulted in the growth of surgeons who
perform bariatric surgery. Unfortunately, not all surgeons may be properly
trained in either bariatric surgery or laparoscopic surgery. Thus, centers of
excellence (COEs) have been created to help identify programs that have the
appropriate surgeons as well as pre-operative and post-operative care. Case
volume, complications, and mortality are recorded and minimal standards are
set. While the true value of becoming a COE is still to be determined, it may
help patients and referring physicians gauge the value of certain programs.
On the other hand, self-reporting and arbitrary volume requirements may
qualify substandard programs and disqualify more deserving programs.
Bariatric Programs
While the rise of bariatric programs can be connected to the increase in
patient demand for the reasons discussed above, to ignore the financial
benefit to the hospitals would be naïve. However, just because a hospital
makes a profit from a service, it does not mean the hospital cannot provide
excellent care. The worry is that some hospitals initiate bariatric programs
without the knowledge of the details that are required to provide
appropriate care. Thus, physicians and patients need to understand what is
needed in a true laparoscopic bariatric program.22
First and foremost, a bariatric surgeon with either sufficient training and/or
experience in laparoscopic bariatric surgery is needed. LRYGB has a steep
learning curve of at least 100 cases and, some believe, even more.3-6 Without
completing a fellowship, it is difficult for a surgeon to perform these cases after
most general surgery residencies. Some surgeons who have tried to ‘dabble’ in
bariatric surgery have had disastrous results at the expense of the patient.
Second, pre-operative education and pathways should be established.
Patients should undergo some formal education, be given adequate
information, and have access to healthcare providers in the bariatric clinic for
questions. This should not be a one-man (or -woman) show.
Clinical pathways during the hospital stay should be established and
implemented.23 These pathways should include specific pathways for preoperative care, operative issues such as anesthesia, recovery room care,
post-operative care, and discharge. Larger equipment should be considered
in these clinical pathways. Lastly, bariatric programs should have a system in
place to provide proper post-operative care. Long-term follow-up is a
requirement so that patients can receive appropriate adjustments after LAGB
and nutritional issues are monitored after LRYGB and LBPD. Partnering with
appropriate services such as gastroenterology, pulmonary, cardiology, and
endocrine gives patients expert care in regard to their sleep apnea, cardiac
disease, diabetes, and other medical issues. In addition, early and late
US GASTROENTEROLOGY REVIEW 2007
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Surgery Laparoscopic Surgery
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complications such as prolonged ventilator support, heart attacks, and
stenosis can be appropriately dealt with.
Conclusions
Laparoscopic bariatric surgery provides one of the most effective methods
of weight loss in the morbidly obese patient. However, no ‘magic pill’ exists
1.
2.
3.
4.
5.
6.
7.
8.
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