Laparoscopic Gastric Bypass

1. Laparoscopic Gastric Bypass Basic Science Conference 2/28/08 Jeff Neale MD

2. BACHGROUND Bariatric surgery is : Currently the only effective treatment for severe obesity. Worldwide, a.) Gastric bypass comprises two thirds of all bariatric procedures b.) Laparoscopic gastric bypass is the most commonly performed bariatric procedure In the United States:, 80% of the Bariatric procedures = gastric bypasses, Over 140,000 bariatric procedures were performed in 2004.

3. HISTORY First performed as a weight loss procedure in 1967 by Mason and Ito A.) Patients post gastrectomy had difficulty gaining weight. B.) The original operation consisted of a 150-mL gastric pouch + loop gastrojejunostomy. C.) This original gastric bypass has been modified significantly. 1.) Roux-en-Y gastrojejunostomy replaced the loop gastrojejunostomy = reduce bile gastritis. 2.) The restrictive component (gastric volume reduction =<20 mL).

4. History Wittgrove and Clark a.) Demonstrated the feasibility of the laparoscopic Roux-en-Y gastric bypass (LRYGB) in 1994. b.) Small series in the late 1990s followed this initial study (weight loss and co-morbidity resolution) = open approach. c.) Several large studies demonstrating the safety and efficacy. d.) The laparoscopic RYGB replicates the open procedure from an anatomic standpoint

6. Candidates 1.) (BMI) greater than or equal to 40 kg/m 2.) BMI greater than or equal to 35 kg/m2 with obesity-related comorbidity. i.e. Diabetes, Htn Preoperative evaluation 1.) Address the patient's known comorbidities 2.) Uncover occult comorbidities a.) coronary artery disease, b.) sleep apnea, c.) obesity hypoventilation syndrome. A multidisciplinary = The team 1.) Nutritionists, 2.) Psychologists 3.) Psychiatrists, 4.) Medical subspecialists a.) cardiovascular, b.) pulmonary, c.) endocrine d.) support is required

7. Patients with ongoing substance abuse or uncontrolled psychiatric disorders are not candidates for bariatric surgery.

8. Mechanism of Weight loss Gastric bypass = hybrid operation a.) Restrictive and malabsorptive mechanism of action. b.) The standard Roux limb = 75 cm The effectiveness a.) Combination of restriction c.) Bypassing the stomach and duodenum ( neuro, horm) b.) Rapid nutrient delivery to the hindgut (neuro, horm) Neurohumoral and gut hormones a.) Satiety b.) Glucose metabolism, Long-limb (150-cm Roux limb) = More malabsorption

9. Access and Exposure 1.) Supine position with the feet together on a footboard. 2.) The operating surgeon stands on the R side of the patient. 3.) Abdominal access a.) 5-mm optical viewing trocar b.) Left upper quadrant Veress needle, c.) Remaining ports are placed under direct vision d.) 5-mm liver retractor, is placed and anchored to the bed with a self-retaining device. Local anesthesia used for all ports

11. The Roux Limb (STEP 1) 1.) The transverse colon and omentum are passed to the upper abdomen 2.) The ligament of Treitz is identified. 3.) The proximal jejunum is then placed in a “C” configuration to help orient the proximal and distal segments. 4.) Divide Jejunum 30 to 50 cm distal to the ligament of Treitz using an Echelon 60, linear cutting stapler with a white load (2.5-mm staples). 5. ) The mesentery of the jejunum divided x 2 firings of the white loads a.) Provide sufficient length of mesentery for tension-free passage of the Roux limb to the gastric pouch. b.) The Roux limb is marked by sewing a Penrose drain to the corner.

12. STEP 1

13. Roux Limb (STEP 2) The Roux limb is measured distally from the Penrose drain for a distance of 75 cm. A longer Roux limb (150 cm) is measured for patients with a BMI greater than 50. The bowel should be straightened (not stretched) against a rigid measuring device such as a marked grasper = Proper length Place a suture to approximate the biliopancreatic limb and the Roux limb side by side.

14. STEP 2

15. ROUX LIMB Step 3 Adjacent enterotomies are made with the Harmonic scalpel). A side-to-side, functional end-to-end jejunojejunostomy is then created using the linear stapler with a white reload

16. STEP 3

17. Remaining enterotomy is closed with another firing of the linear stapler. Inspected for kinking or obvious staple line failures Reinforcing sutures are placed using 3-0 braided nonabsorbable sutures One reinforcing stitch is placed between the stapled end of the biliopancreatic limb and the Roux limb (“Brolin stitch”). Another is placed proximally at the crotch between the biliopancreatic limb and Roux limb. The mesenteric defect between the biliopancreatic and Roux limb is then closed with a running nonabsorbable

18. Step 4

19. Roux Limb Step 5 Decrease tension on the Roux limb as it passes over the transverse colon = greater omentum divided This omental dissection begins at the level of the midtransverse colon with the omentum flipped up toward the diaphragm. The Harmonic scalpel is used to completely divide the omentum and the separated leaves are brought down below the transverse colon. The Roux limb is passed upward between the leaves of the divided omentum to the gastric pouch in the antecolic and antegastric position The attached Penrose drain provides an atraumatic handle for this maneuver

21. Gastric Pouch The patient is placed in the steep reverse Trendelenburg position Create a window in the clear space of the gastrohepatic ligament with the Harmonic scalpel. A 60-mm linear stapler is fired toward the lesser curvature of the stomach to divide the lesser omentum. Divides descending branch of the left gastric artery is transected The main trunk of the left gastric is preserved = Main blood supply to the gastric pouch.

22. THE POUCH.. STEP 1 1.) Use a linear stapler. 2.) Fire stapler 1 cm distal to the esophageal fat pat 3.) Completed after the lesser omentum is divided with a stapler. 4.) Two or three vertical staple firings directed to the angle of His results in a vertically oriented 15-mL gastric pouch

23. The Gastric Pouch Separate gastric Pouch and remenant = minimize the chances of developing a gastrogastric fistula. Dissect the pouch from the L crus = mobility of the pouch+ decreases tension on the gastrojejunal anastomosis.

24. GastroJejunosotmy 1.) LINEAR 2.) CIRCULAR TRANSORAL 3.) CIRCULAR TRANSABDOMINAL 4.) HANDSEWN

25. Linear GastroJejunostomy STEP 1 A posterior suture line approximates the gastric pouch and the Roux limb.

26. GastroJejunosotmy Step 2 1.) Create a gastrotomy and enterotomy with Harmonic scalpel 2.) The linear stapler (blue load) is placed 1.5 cm into each lumen, closed, and fired

27. Gastrojejunosotmy Step 3 The common opening is then closed in two layers over an endoscope. The anastomosis is checked for bleeding and leaks using the endoscope.

28. Linear Gastrojejunosotmy The inner layer of suture = absorbable to prevent foreign body reaction or marginal ulcer formation. The endoscope a.) Sizes the anastomosis to 30 French, b.) Allows inspection for anastomotic bleeding at the time of the procedure, c.) Provides insufflation for leak testing. d.) A Jackson-Pratt drain is placed posterior to the anastomosis e.) Omentum is then sutured in place over the top of the pouch and the gastrojejunal anastomosis (“Schauer cap”). Some groups suture the Roux limb to the gastric remnant as it passes over it with a single nonabsorbable stitch to minimize the risk of twisting.

29. Final Steps LEAK TEST Regardless DO A leak test at the end of the case. a.) Occlude the Roux limb distal to the gastrojejunostomy with a bowel clamp, b.) Submerge the anastomosis in saline, c.) Insufflating the proximal Roux limb and gastric pouch with air using an endoscope. d.) Any area of the anastomosis that bubbles with insufflation should be carefully localized and oversewn.

30. Final StepsCholecystectomy 1.) If Patient found to have symptomatic cholelithiasis during the preoperative evaluation. 2.) Do not prophylactically remove the gallbladder and patients with an intact gallbladder are placed on ursodiol for 6 months postoperatively. 3.) Core needle liver biopsy routinely as part of every bariatric procedure to document the degree of nonalcoholic fatty liver disease present.?????? 4.) Final inspection is performed looking for a.) Bowel kinks or twists, b.) Staple line bleeding or failure, c.) Retained sponges (if used during the gastric dissection).

31. Transoral circular stapler method 1.) The gastric pouch is created. 2.) Endoscope is passed into the pouch 3.) Snare is pushed through a small gastrotomy.

32. Transoral circular stapler method Guidewire is passed through a laparoscopic port, Grasped by the snare, and pulled out of the patient's mouth. The anvil is attached to the guidewire and pulled antegrade into the gastric pouch.

33. Transoral circular stapler method The circular stapler is placed in the open end of the Roux limb. The stapler and anvil are connected and the stapler is fired to create a circular stapled anastomosis.

34. Transoral circular stapler method The open Roux limb is closed with a linear stapler. The anastomosis is reinforced with sutures A closed suction drain is placed adjacent to the anastomosis.

36. Post Operative Management Pain control is maintained with patient-controlled anesthesia. Antiemetic therapy is started in the operating room. Essential preoperative medications are continued in intravenous form until the patient is started on liquids. Patients ambulate with assistance the evening of surgery and early, Frequent use of incentive spirometry is encouraged. Patients are kept NPO the night of surgery and a Gastrografin swallow pod day 1 on every patient. If the swallow study is negative for leaks or obstruction = clear liquid diet.

37. Post Operative Management The majority of patients are discharged to home on postoperative day 2 a.) normal vital signs, b.) regular ambulation, c.) adequate pain control with oral analgesics, d.) tolerating liquids. DC JP POST OP DAY 7 IF: If drainage is minimal and clear No signs or symptoms of an anastomotic leak, The Jackson-Pratt drain is removed in the office on postoperative day 7.

38. Post Operative Management Tachycardia in the postoperative LRYGB patient 1.) GREATER THAN 120 = LEAK UNTIL PROVEN a.) Only presenting sign of LEAK Tachypnea or decreasing oxygen saturations 1.) Early sepsis from a leak 2.) Pulmonary embolism (PE). 3.) Anastomotic leak and PE are the two most common causes of death after gastric bypass 4.) THE CLINICAL PICTURE IN THESE PATIENTS ARE INDISTINGUISHABLE

39. Post Operative Management Major complications = Subtle findings in these patients Physical examination findings 1.) (peritoneal irritation) ARE EXCEPTIONS NOT THE RULE. 2.) AGGRESSIVELY WORK UP POST OP A.) Fever B.) Tachycardia, C.) Tachypnea OR even IF ………diagnostic tests are inconclusive or negative BUT clinical suspicion for a leak is high.

40. EARLY COMPLICATIONS The incidence of major postoperative 8% to 15%. A.) Anastomotic leaks = 1% to 5% in open and Lap B.) Leak rates, particularly with the laparoscopic technique, decrease with surgeon experience. C.) Tract hemorrhage occurs up to 4% occurs at the gastrojejunostomy or the gastric remnant staple line. Note: Endoscopic access to the excluded stomach is not possible, and this can make the diagnosis and management of gastric remnant bleeding difficult.

41. Early Complications D.) Thromboembolic = 1% of patients. high risk for deep venous thrombosis (DVT) and PE perioperative prophylaxis. Some groups continue prophylaxis beyond discharge from the hospital for patients a.) Hx of a DVT or PE or a BMI greater than 55 b.) Discontinue it on a case-by-case basis depending on the patient's risk and activity level.

42. Early Complications Acute dilation of the gastric remnant = less than 1% Catastrophic complication. Cause = obstruction of the biliopancreatic limb. Severe epigastric pain in conjunction with gastric distension a.) Plain abdominal radiograph b.) Computed tomography scan is diagnostic. Tx 1.) urgent percutaneous gastrostomy tube decompression. 2.) If delayed and the gastric remnant staple line disrupts = RAPID deterioration. 3.) The biliopancreatic limb obstruction can be addressed surgically after the patient has stabilized following gastric decompression.

43. Early Complications Wound infection = < 10% of the time after LRYGB. a.) Infections of laparoscopic trocar sites Antibiotics Local wound care Contribute little to overall morbidity.

44. Late Complications Marginal ulceration Occurs at the gastrojejunostomy 1% to 16% Associated with ischemia, smoking, excessive acid exposure (gastrogastric fistula), large pouch size, retained anastomotic suture, nonsteroidal anti-inflammatory use, and Helicobacter pylori infection. First 2 months after surgery Treated with acid suppression and elimination of any aggravating factors.

45. Late Complications Bowel obstruction Most commonly results from an internal hernia Occurs 1% to 10% of the time. IF symptoms of bowel obstruction should be explored NOT multiple radiologic tests or several days of nonoperative management. IF patients present with episodic abdominal pain or symptoms of recurrent partial small bowel obstruction, laparoscopic exploration should be performed. a.) Most often, these symptoms are due to intermittent bowel herniation through a mesenteric defect.

46. Late complications Anastomotic stricture at gastrojejunostomy, 1.) Technical factors a.) Tension on the Roux limb or pouch ischemia b.) Chronic marginal ulceration. c.) Circular stapler, particularly the 21-mm size d.) Most strictures occur 1 to 3 months after surgery. Present with a.) dysphagia, b.) nausea, c.) vomiting Tx: Endoscopic dilation of the stricture. In most cases, one or two endoscopic balloon dilations are curative.

47. Late complications Nutritional deficiencies can occur after RYGB. Deficiency of iron (6% to 52%), Folate (22% to 63%) Vitamin B12 (3% to 37%) are common a.) Anemia found in up to 54% of patients.

48. Long Limb Complications Higher rates of nutritional complications a.) Greater degrees of malabsorption b.) Protein calorie malnutrition requiring a revision to lengthen the common channel.