Limits...
Laparoscopic adjustable banded roux-en-y gastric bypass as a primary procedure for the super-super-obese (body mass index > 60 kg/m²).

Dillemans B, Van Cauwenberge S, Agrawal S, Van Dessel E, Mulier JP - BMC Surg (2010)

Bottom Line: Roux-en-Y gastric bypass (RYGB) is associated with failure to achieve or maintain 50% excess weight loss (EWL) or BMI < 35 in approximately 15% of patients.At that time, filling of the band can be started resulting in further gastric pouch restriction and increased weight loss.Moreover, besides improving the results of total weight loss, a gradual filling of the band can as well prevent the RYGB patient from weight regain if restriction would fade away with time.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of General Surgery, AZ Sint-Jan Hospital AV, Brugge, Belgium. bruno.dillemans@azbrugge.be

ABSTRACT

Background: Currently, there is no consensus opinion regarding the optimal procedure of choice in super-super-morbid obesity (Body mass index, BMI > 60 kg/m²). Roux-en-Y gastric bypass (RYGB) is associated with failure to achieve or maintain 50% excess weight loss (EWL) or BMI < 35 in approximately 15% of patients. Also, percent EWL is significantly less after 1-year in the super-super-obese group as compared with the less obese group and many patients are still technically considered to be obese (lowest post-surgical BMI > 35) following RYGB surgery in this group. The addition of adjustable gastric band (AGB) to RYGB has been reported as a revisional procedure but this combined bariatric procedure has not been explored as a primary operation.

Methods: In a primary laparoscopic RYGB, an AGB is drawn around the gastric pouch through a small opening between the blood vessels on the lesser curve and the gastric pouch. The band is then fixed by suturing the gastric remnant to the gastric pouch both above and below the band to prevent slippage.

Results: Between November 2009 and March 2010, 6 consecutive super-super-obese patients underwent a primary laparoscopic adjustable banded Roux-en-Y gastric bypass procedure at our institution. One male patient (21 years, BMI 70 kg/m²) developed a pneumonia postoperatively. No other postoperative complications were observed.

Conclusion: To the best of our knowledge, this is the first series of patients that underwent a laparoscopic adjustable banded RYGB as a primary operation for the super-super obese in the indexed literature. With the combined procedure, a sequential action mechanism for weight loss is to be expected. The restrictive, malabsorptive and hormonal working mechanism of the RYGB will induce weight loss from the start reaching a stabilised plateau of weight after 12 - 18 months. At that time, filling of the band can be started resulting in further gastric pouch restriction and increased weight loss. Moreover, besides improving the results of total weight loss, a gradual filling of the band can as well prevent the RYGB patient from weight regain if restriction would fade away with time.

Show MeSH

Related in: MedlinePlus

Laparoscopic adjustable gastric banded Roux-en-Y gastric bypass. Schematic representation of the Roux-en-Y gastric bypass construction with the adjustable band wrapped around the gastric pouch.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
getmorefigures.php?uid=PMC2992483&req=5

Figure 1: Laparoscopic adjustable gastric banded Roux-en-Y gastric bypass. Schematic representation of the Roux-en-Y gastric bypass construction with the adjustable band wrapped around the gastric pouch.

Mentions: One dose of cefazoline 1 g was given IV at induction of general anaesthesia. The patients were placed in the supine position, split-leg with reverse Trendelenberg position along with slight flexion of the hip to help increase surgical abdominal workspace [21]. The surgeon stood between the legs. A video monitor is positioned at the level of the patient's head. A 30° angle scope is used. Abdominal insufflation with carbon dioxide (CO2) is achieved using a Veress needle. Intra-abdominal pressures are maintained at 15 to 17 mmHg. A five-port technique was employed: a 10 mm port 10-15 cm below the xiphoid process, a 5 mm port high epigastric on the midline, a 12 mm port in the right upper quadrant and a 15 mm and 12 mm port in the left upper quadrant. The latter two ports are placed on the same line of the 10 mm port with the 15 mm port in the middle between the 10 mm and the 12 mm port. The former 12 mm port is placed somewhat higher above the same line (sub costal). Since we perform a standardized fully stapled laparoscopic RYGB procedure, the procedure started with the creation of the gastric pouch following the same principles as previously published by our group [22]. After creation of the gastric pouch, an atraumatic grasper was passed through a small opening between the blood vessels on the lesser curve and the gastric pouch 1-2 cm above the horizontal cut edge of the pouch. Following this step, an AGB was introduced via the 15 mm port, drawn around the pouch and locked into place (Figure 1). In the first four patients, a Heliogast® HAGE band (Helioscopie, France) has been placed. The last two patients received a newer type of band, the Heliogast® HAGB band (Helioscopie, France), which is easier to fit because of its lesser diameter and width (Figure 2).


Laparoscopic adjustable banded roux-en-y gastric bypass as a primary procedure for the super-super-obese (body mass index > 60 kg/m²).

Dillemans B, Van Cauwenberge S, Agrawal S, Van Dessel E, Mulier JP - BMC Surg (2010)

Laparoscopic adjustable gastric banded Roux-en-Y gastric bypass. Schematic representation of the Roux-en-Y gastric bypass construction with the adjustable band wrapped around the gastric pouch.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC2992483&req=5

Figure 1: Laparoscopic adjustable gastric banded Roux-en-Y gastric bypass. Schematic representation of the Roux-en-Y gastric bypass construction with the adjustable band wrapped around the gastric pouch.
Mentions: One dose of cefazoline 1 g was given IV at induction of general anaesthesia. The patients were placed in the supine position, split-leg with reverse Trendelenberg position along with slight flexion of the hip to help increase surgical abdominal workspace [21]. The surgeon stood between the legs. A video monitor is positioned at the level of the patient's head. A 30° angle scope is used. Abdominal insufflation with carbon dioxide (CO2) is achieved using a Veress needle. Intra-abdominal pressures are maintained at 15 to 17 mmHg. A five-port technique was employed: a 10 mm port 10-15 cm below the xiphoid process, a 5 mm port high epigastric on the midline, a 12 mm port in the right upper quadrant and a 15 mm and 12 mm port in the left upper quadrant. The latter two ports are placed on the same line of the 10 mm port with the 15 mm port in the middle between the 10 mm and the 12 mm port. The former 12 mm port is placed somewhat higher above the same line (sub costal). Since we perform a standardized fully stapled laparoscopic RYGB procedure, the procedure started with the creation of the gastric pouch following the same principles as previously published by our group [22]. After creation of the gastric pouch, an atraumatic grasper was passed through a small opening between the blood vessels on the lesser curve and the gastric pouch 1-2 cm above the horizontal cut edge of the pouch. Following this step, an AGB was introduced via the 15 mm port, drawn around the pouch and locked into place (Figure 1). In the first four patients, a Heliogast® HAGE band (Helioscopie, France) has been placed. The last two patients received a newer type of band, the Heliogast® HAGB band (Helioscopie, France), which is easier to fit because of its lesser diameter and width (Figure 2).

Bottom Line: Roux-en-Y gastric bypass (RYGB) is associated with failure to achieve or maintain 50% excess weight loss (EWL) or BMI < 35 in approximately 15% of patients.At that time, filling of the band can be started resulting in further gastric pouch restriction and increased weight loss.Moreover, besides improving the results of total weight loss, a gradual filling of the band can as well prevent the RYGB patient from weight regain if restriction would fade away with time.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of General Surgery, AZ Sint-Jan Hospital AV, Brugge, Belgium. bruno.dillemans@azbrugge.be

ABSTRACT

Background: Currently, there is no consensus opinion regarding the optimal procedure of choice in super-super-morbid obesity (Body mass index, BMI > 60 kg/m²). Roux-en-Y gastric bypass (RYGB) is associated with failure to achieve or maintain 50% excess weight loss (EWL) or BMI < 35 in approximately 15% of patients. Also, percent EWL is significantly less after 1-year in the super-super-obese group as compared with the less obese group and many patients are still technically considered to be obese (lowest post-surgical BMI > 35) following RYGB surgery in this group. The addition of adjustable gastric band (AGB) to RYGB has been reported as a revisional procedure but this combined bariatric procedure has not been explored as a primary operation.

Methods: In a primary laparoscopic RYGB, an AGB is drawn around the gastric pouch through a small opening between the blood vessels on the lesser curve and the gastric pouch. The band is then fixed by suturing the gastric remnant to the gastric pouch both above and below the band to prevent slippage.

Results: Between November 2009 and March 2010, 6 consecutive super-super-obese patients underwent a primary laparoscopic adjustable banded Roux-en-Y gastric bypass procedure at our institution. One male patient (21 years, BMI 70 kg/m²) developed a pneumonia postoperatively. No other postoperative complications were observed.

Conclusion: To the best of our knowledge, this is the first series of patients that underwent a laparoscopic adjustable banded RYGB as a primary operation for the super-super obese in the indexed literature. With the combined procedure, a sequential action mechanism for weight loss is to be expected. The restrictive, malabsorptive and hormonal working mechanism of the RYGB will induce weight loss from the start reaching a stabilised plateau of weight after 12 - 18 months. At that time, filling of the band can be started resulting in further gastric pouch restriction and increased weight loss. Moreover, besides improving the results of total weight loss, a gradual filling of the band can as well prevent the RYGB patient from weight regain if restriction would fade away with time.

Show MeSH
Related in: MedlinePlus