Laparoscopic gastric bypass

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  • Universitäts Klinik Witten Herdecke

    Prof. Dr. med. Gebhard Reiss

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  • Introduction

    The incidence and prevalence of morbid obesity with its associated comorbidities is increasing worldwide, particularly in Western countries. According to the WHO, 600 million people are obese (BMI > 30 kg/m2).

    As evidenced by high-quality data, bariatric and metabolic surgical procedures are the most effective and long-lasting treatment modalities in morbid obesity and outperform nonsurgical multimodal regimens.

    In addition to achieving sustained weight loss, surgery can also successfully treat obesity-related comorbidities, such as type 2 diabetes, arterial hypertension, lipid metabolic disorders, and sleep apnea syndrome.

    The proliferation and acceptance of bariatric surgery has increased significantly worldwide over the past 20 years (approx. 150,000 procedures in 2003; 470,000 in 2013).

    Successful bariatric surgery outcome is evaluated based on effective weight loss and a positive effect on associated morbidities.

    Roux-en-Y gastric bypass (RYGB) is the gold standard of bariatric surgery, accounting for about 45%.

    The large number of complex changes with metabolic effects unfolding in the enterohumoral axis because of surgery go well beyond weight loss.

    The new term “metabolic surgery” reflects the expanded indication. It is expected that bariatric surgery will play a greater role in the management of metabolic syndrome.

    Many patients with type 2 diabetes show complete remission within days of surgery and long before significant weight loss. The current discussion has evolved to the issue of treating normal weight and slightly overweight diabetics by metabolic surgery as well.

    With the advent of laparoscopic surgical techniques, these procedures, initially regarded as high-risk surgery, can now be effected with an acceptable risk profile.

    Bariatric and metabolic operations are not included in the Standard Benefits Catalog of the German Health Insurance providers. Therefore, each patient must apply individually to his/her provider for this type of surgery.

  • Physiological mechanisms of gastric bypass

    While restriction and malabsorption are prerequisites for successful treatment, hormonal and neural mechanisms appear to be the chief determinants in improving the diabetic metabolism.

    The complex interplay of hunger and satiety, as well as metabolism and energy balance, undergoes specific change as a result of this type of surgery.

    In addition to restriction and malabsorption, the postgastric bypass modified gastrointestinal anatomy induces manifold physiological changes, for example, in gastrointestinal hormone secretion, neuroendocrine signaling and the intestinal microbiome.

    Compared with purely restrictive procedures (gastric banding), following bypass surgery patients experience early satiety and reduced hunger. All procedures bypassing the gastric fundus as the main site of ghrelin production have a lasting impact on hunger suppression.

    Furthermore, bypassing the duodenal receptors and proximal jejunum from intestinal transit and rapidly transporting food to distal small bowel segments stimulates enterohormonal secretion and improves glucose metabolism.

    More than 80% of postsurgery patients can discontinue insulin treatment or oral medication.

  • Technique of Proximal Gastric Bypass (RYGBP)

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    In laparoscopic Roux-en-Y gastric bypass a small gastric pouch (20-30 ml) is first fashioned  by dividing the subcardiac stomach with staplers from the rest of the stomach. The division must be total with no tissue bridge to the rest of the stomach.

    Then the fashioned gastric pouch is anastomosed with the Roux-en-Y jejunal limb. Thus, food transit will bypass the duodenum and part of the jejunum. The brought-up Roux limb is known as the “alimentary or efferent limb” and is anastomosed with the “biliopancreatic or afferent limb” 150 cm distal to the enteroenterostomy. Following the anastomosis of these two limbs, the actual absorption of food takes place in the “common channel”.

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  • Indications

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  • Contraindications

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  • Preoperative diagnosis

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  • Special preparation

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  • Enlightenment

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  • Anesthesia

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  • Positioning

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  • Operating room setup

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  • Special instruments and holding systems

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  • Postoperative management

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  • Fashioning the gastric pouch

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    After starting the operation (Creating the pneumoperitoneum, working trocar placement, exploring the abdominal cavity) expose the angle of His.

    Then begin fashioning the gastric pouch at the lesser curvature 2 cm inferior to the gastroesophageal junction. In order to avoid bleeding complications and assure blood flow to the pouch, spare the left gastric artery which will supply the gastric pouch. Begin dividing the stomach in a horizontal direction with a linear stapler (staple height 3.5 mm).

    Continue the dissection in triangular fashion toward the left crus of diaphragm. It serves as an anatomical landmark.

    Transect the entire gastric fundus to bypass the production site of the enterohormone ghrelin from the intestinal transit and prevent subsequent dilation.

    Finally, ensure adequate ultrasound hemostasis at the staple line.

  • Measuring the biliodigestive limb and bringing it up into the upper abdomen

    After completely dividing the stomach, expose the ligament of Treitz. Divide the greater omentum if very fat.  About 50 cm distad to the ligament of Treitz, bring the jejunal limb antecolically to the gastric pouch. When measuring it is helpful to always keep the efferent limb on the right on the monitor screen with the instrument of the right hand to avoid misidentification of the limbs. The use of measuring tools is helpful.

    Alternative routes to the gastric pouch for the efferent limb.

    Tip: To avoid fashioning a limb that is too short, first check that the efferent limb is long enough to reach the pouch. If the limb proves to be too short nevertheless, it is recommended to fashion a primary gastric sleeve-like pouch and/or skeletonize the efferent limb or bring the limb up via a retrocolic retrogastric route.

  • Parallel anchoring of the limb on the gastric pouch

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    Anchor the jejunal limb tension-free on the gastric pouch with two sutures.

    Note: If the limb is anchored too far craniad, this will result create a distal pouch reservoir with overflow phenomenon; if the limb is anchored too far caudad, this will increase the risk of a dumping syndrome. The limb should therefore be placed at the second staple line and tailored to the shape and size of the pouch.

    Tip: To avoid a twisted limb (“blue limb” syndrome), bring up the limb under direct vision (with the mesentery pointing to the left). Correct and eliminate any limb rotation.

    Limb misidentification must be ruled out at all cost and this requires consistent identification of the ligament of Treitz. Any misidentification of the limbs must be corrected immediately since otherwise the overstretched stomach (distension) carries the risk of cardiac arrest.

  • Fashioning the antecolic retrogastric gastroenterostomy (linear anastomosis of the posterior wall)

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    Create the gastroenterostomy by opening both the gastric pouch and efferent limb in parallel with the ultrasound dissector. Open the gastric pouch on its posterior wall.

    This can be done with electrocautery hook electrodes/shears, ultrasound or Ligasure.

    Close the posterior wall of the anastomosis with a linear stapler (blue cartridge) and leave the anterior wall open.

    Tip: Avoid posterior perforation by carefully keeping the anchor suture under tension when making the incision, and oversew if necessary.
    If intestinal continuity was severed already prior to the gastroenterostomy and the distance from the end of the efferent limb is too long, resect the ear of the small intestine.

  • Fashioning the gastroenterostomy (suture closure of the anterior wall)

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    Before closing the gastric and intestinal openings, insert a sizer into the efferent jejunal limb.

    Then close the anastomosis with a running suture and secure it with interrupted sutures.

    Alternatively, fashion the gastroenterostomy with an EEA stapler or suture all of it by hand.

    Tip: Avoid postoperative anastomotic stricture by advancing an 8 mm probe across the anastomosis to prevent posterior wall entrapment when closing the anterior wall.

  • Inspecting the anastomosis

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    After fashioning the anastomosis leakage test it with methylene blue or by gas insufflation. Carefully inspect the anastomosis from all sides. Meticulous testing and rinsing with water are needed to detect even small amounts of the blue dye solution on the posterior wall.

    Note: In primary procedures fashion the gastrojejunostomy as a combined anastomosis with linear stapler anastomosis of the posterior wall and suture closure of the anterior wall. In revision surgery and BPD/DS operations suture the anastomosis completely by hand.

  • Transecting the small intestine / dividing the afferent limb

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    After creating a mesenteric window, divide the proximal small bowel limb with a stapler (blue cartridge 45 mm).

    Note: Transecting the intestinal continuity after the gastroenterostomy has been fashioned should be left in the hands of experienced centers. Alternatively, transect the intestinal continuity already prior to fashioning the gastroenterostomy.

    Tip: Keeping the mesenteric window small and close to the bowel will help prevent any excessive skeletonization and thus herniation, rotation, torquing, and kinking of the enteroenterostomy (EE).

    Avoid this complication by anchoring the enteroenterostomy with a nonabsorbable suture (Brolin stitch) at the end of surgery.

  • Anchoring suture at the biliodigestive stump/measuring the efferent limb

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    After completing the anastomosis, place an anchoring suture on the stump of the afferent limb. Then measure the efferent limb with graduated instruments or measuring tools. Measure the intestinal length with the bowel unstretched.

    Read more here about the length of the efferent limb.

    Tip: Relying only on atraumatic instruments and manipulating these solely under direct vision will help prevent, as much as possible, any forceps perforation of the small bowel. In the event of perforation, carefully oversew.

  • Fashioning the enteroenterostomy I

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    Fashion the enteroenterostomy as a side-to-side anastomosis. To that effect, open the two limbs with the ultrasound dissector and fashion the Roux-en-Y anastomosis with a linear stapler.

    Tip: Carefully oversew any iatrogenic perforation of the posterior wall. Perforation may be avoided by pulling the anchor suture craniad under tension.

  • Fashioning the enteroenterostomy II

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    First, close the anterior defect in the distal region with one interrupted suture. This can then act as a stay suture while continuing to close the proximal part of the staple line openings. Follow this with a meticulous absorbable suture. Finally, inspect the anastomosis from all sides to detect any leakage early. Carefully oversew any leaks detected.

    Tip: If suture line failure is suspected in the early postoperative course, early intervention with oversewing the leakage is needed.

  • Brolin stitch

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  • Closing the Petersen space

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  • Intraoperative complications

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  • Postoperative complications

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  • Literature summary

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  • Ongoing trials on this topic

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  • References on this topic

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  • Reviews

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  • Guidelines

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  • literature search

    Literature search under: http://www.pubmed.com