The laparoscopic Roux-en-Y gastric bypass is considered as the golden standard among the surgical bariatric options. Despite the growing worldwide spread and surgical experience of this procedure, LRYGB remains a technically challenging procedure with a substantial morbidity and mortality.
Buchwald et al. reported in a large meta-analysis a mortality rate of 0.16% for LRYGB [17
]. The mortality rate in our series was 0.04% which is among the lowest reported incidences in literature. Flum et al concluded that advancing age, male sex, and lower surgeon volume are associated with a higher risk of early death after bariatric surgery [18
]. Although the mean BMI of our patient population is rather low compared to other series, we are convinced that besides the high patient volume, the full stapling and extensive standardization of the procedure are the main reasons for these favorable results. In this standardization, the procedure is split into different phases in which every participant (surgeon, registrar, scrub nurse, anesthesiologist) has a specific role. Every single laparoscopic maneuver has been completely rationalized which contributed to a substantial shortening of the length of the operative time. One must fear postoperative leaks as the most important cause of surgical related mortality. Gastric or intestinal leaks can result in severe peritonitis, sepsis, and multi-organ failure. Male gender, re-operation, older age, a BMI >50 kg/m2
and surgeon experience are all associated with poor operative outcome and a greater leakage rate [19
]. The most common site for an anastomotic leak is the gastro-jejunostomy [20
The leakage rate in our series was 0.19% (n
5). One patient underwent open re-operation and the other four patients were treated laparoscopically. Different studies report an overall leakage rate ranging from 0.1% to 5.25% [21
] (Table ). In a review of 6,135 patients in 13 selected series of laparoscopic RYGB, the mean leakage rate was 1.4% (range 0–4.3) [20
]. The low leakage rate in this study is in our opinion attributed to a standardized anastomotic technique with suture reinforcement if necessary and the construction of a rather long gastric tube. The anastomotic integrity of the gastro-jejunostomy is intra-operatively assessed by high-pressure testing of this anastomosis with methylene blue. The methylene blue test has been reported to be 100% sensitive and to have no side-effects [32
Comparative overall leakage rate after Roux-en-Y gastric bypass
We prefer to use the circular stapler to complete the gastro-jejunostomy. Compared to the linear technique, this technique does not require closure of a common opening, eliminating a possible leakage site. Furthermore, traction on the gastro-jejunostomy is limited due to an equal distribution of forces on the anastomosis. Additionally, the circular stapler with a fixed diameter reproduces the opening of the anastomosis in each case without the subjective sizing of the other techniques [22
Insertion of the circular stapler (25 mm Premium Plus CEEA) with the anvil trans-abdominally is easy, safe and quick. Passing the anvil into the gastric pouch trans-orally is an alternative but surgeons should be aware of possible technical difficulties as hypopharyngeal or esophageal injury has been described [33
The technique of the FS-LRYGB in our center involves the construction of a rather long (5–6 cm) but narrow pouch. A longer pouch facilitates the construction of the gastro-jejunostomy importantly and decreases the traction on it, especially when the alimentary limb is pulled up antecolically. Capella et al. are convinced that long narrow pouches are the most effective operations in bariatric surgery. Long narrow pouches have less tendency to enlarge and delay the transit of food to a greater degree than wider pouches, according to the Laplace’s and Poiseuille’s Laws. However, pouches are not perfect cylinders; the walls are not rigid and are of variable distensibility. Strict application of these physical laws to the clinical setting will require further research [35
Hemorrhage was the most common in-hospital complication (3.42%) occurring after FS-LRYGB in our experience. This number is consistent with the reported 3.1% incidence by Spaw et al. [36
] in a literature review of 2,895 patients. The most common sites of bleeding are the staple lines which are likely to bleed either extra-luminally (intra-abdominally) or intra-luminally. At this point, additional care is taken to identify and control bleedings intra-operatively. Early recognition of postoperative bleeding is crucial. Careful clinical and hemodynamic monitoring of the patient in combination with the observation of the output of the intra-abdominal drain can avoid hypovolemic shock. In this study, 74.16% of postoperative bleedings were managed conservatively without the need of a surgical re-intervention. More recently, endoscopic management has been introduced to control bleeding from the gastro-jejunal staple line.
Early stenosis still remains an important issue. Of the 2,606 patients, 4 (0.15%) were re-admitted within 30 days because of vomiting due to a narrowing of the gastro-jejunal anastomosis. All cases were treated endoscopically with balloon dilatation. However, stenosis becomes more apparent after the 30-day period. The overall stenosis rate in our series with a completed follow-up of 3 months was 0.95% (n
24 out of 2,521 patients; follow-up rate of 95.3%).
Small bowel obstruction occurred in nine patients (0.35%) and nearly all were related to hernias. Seven out of nine patients had a lateral entrapment at the left lateral trocar site and required re-operation. This problem has now been overcome by using standard direct visual closure of the trocar site with the Endo Close (Covidien, USA) system.
In the past, we did not close Petersen’s space. Although the antecolic antegastric technique has the least incidence of internal hernias, we have, as of March 2008, started closing Petersen’s space. To date, there is sufficient data suggesting that this closure is better done on a routine basis [37
]. However, recently, Madan et al. [40
] suggest that mandatory closure of mesenteric defects might potentially create an increased risk of complications and costs without a real added benefit for the patient.
In this study, the re-operation rate was 1.57% and the readmission rate 1.30%.
In other publications, readmission rates after gastric bypass range from 0.6% to 6.6% [41
]. A nationwide in-patient sample estimated that the rates of unexpected re-operation during the same admission ranged from 6 to 9% [45