2005 SAGES Abstracts

POSTER ABSTRACTS
MD,Ajay K Chopra MD, Patrick R Reardon, MD, Wiljon Beltre,
MD, Ajay K Chopra, MD, Department of Surgery, University of
Texas Health Science Center at Houston, The Methodist
Hospital, Houston, Texas
Introduction: Laparoscopic roux-y gastric bypass (RYGB) is a
frequently performed procedure. We present our technique for
using the gastric antrum as an anchor point for the roux limb
during and after the operation.
Methods: During RYGB we perform the creation of the roux
limb as the first portion of the operation. The patient is in a
flat, supine position during this portion of the surgery. We routinely
use an antecolic, antegastric approach for the roux limb.
During creation of the gastric pouch and gastrojejunostomy,
we place the patient in a steep head-up, reverse Trendelenburg
(RT) position. This position makes retrieval of the proximal end
of the roux limb difficult later in the surgery. Therefore, once
the roux limb has been created, the greater omentum is divided
in its midportion. The roux limb is then properly oriented
and the proximal end brought up and sutured to the gastric
antrum. The patient is then placed in RT position and the
suture holds the roux limb in proximity and properly oriented
without interfering with the gastric pouch creation. When the
gastric pouch has been created, the roux limb is then cut loose
from the antrum and advanced to create the gastrojejunostomy.
When the gastrojejunostomy is complete, the roux limb is
then sutured to the adjacent antrum as it passes over this
area, keeping slack on the portion of the roux limb proximal to
the anchor suture. When the patient is in an upright position
postoperatively, this should let the antrum bear the weight of
the roux limb instead of the gastrojejunostomy anastomosis
doing so.
Conclusion: Suturing the roux limb to the gastric antrum is
beneficial during and after laparoscopic RYGB. We believe that
our described technique makes it easier to find the proximal
roux limb at the time of antecolic, antegastric, roux-Y limb formation.
In addition, we believe that, postoperatively, it will
cause the antrum of the gastric remnant to bear the weight of
the roux limb when the patient is upright, and not the gastrojejunotsomy
anastomosis. This may lead to fewer leaks and a
lower stenosis rate.
P086–Bariatric Surgery
GASTROTOMY WITH ANVIL ?DUNK?: A NOVEL TECHNIQUE
FOR GASTROJEJUNOSTOMY DURING LAPAROSCOPIC
ROUX-EN-Y GASTRIC BYPASS, M B Peters MD,H F Ojeda
MD,S Cooper BS,W E Fisher MD,D Camacho MD, D J
Reichenbach MD, J F Sweeney MD, Michael E. DeBakey
Department of Surgery, Baylor College of Medicine
OBJECTIVE: Many techniques for performing the gastrojejunostomy
required in the laparoscopic roux-en-Y gastric
bypass (LRYGB) have been described. The current study presents
the results of a previously unreported method. METH-
ODS: Twenty-one patients (2 males and 19 females) with morbid
obesity underwent laparoscopic roux-en-y gastric bypass
over a 5-month period. The gastrojejunostomy was created by
performing a gastric transection to form a 20-30cc pouch using
a linear stapler, followed by gastrotomy with an ultrasonic
scalpel along the anterior surface of the pouch. A purse string
suture is then placed circumferentially using standard laparoscopic
intracorporeal suturing with an endo-stitch device. (US
Surgical Corporation, Hartford, Connecticut) Finally a 25mm
circular stapler anvil is placed within the abdomen via the
15mm left lower quadrant port site. The shaft of the anvil is
grasped, and the head of the anvil is ?dunked? into the gastrotomy.
The purse string is then tied intracorporeally. RESULTS:
A total of 21 patients have undergone LRYGB at our institution
using this technique. The early results have been excellent in
all cases with no leaks, no strictures, and no obstructions.
CONCLUSION: The gastrotomy with anvil dunk is a reproducible
and safe method of constructing the gastrojejunostomy.
It is an advanced laparoscopic technique, which closely
resembles open surgical techniques and provides a safe alternative
to existing methods.
P087–Bariatric Surgery
REVISIONAL BARIATRIC SURGERY: LESSONS LEARNED,
Adheesh A Sabnis MD, Bipan Chand MD, Department of
General Surgery, Minimally Invasive Surgery Center, Cleveland
Clinic Foundation
Introduction: A historical review of bariatric operations reveals
surgeries that have fallen out of favor as a result of poor outcomes
and complications. Complications include mal-absorptive
syndromes, severe gastroesophageal reflux, anastomatic
strictures, and inadequate long-term weight loss. Revisional
surgery has itself many complications including sepsis and
failure to improve on weight loss.
Methods: A series of 20 patients underwent revisional operations
over a three year period at the Cleveland Clinic
Foundation. Previous operations included vertical banded gastroplasty
(11), roux-en-y gastric bypass (4), horizontal gastroplasty
(3), bilopancreatic diversion (1) and jejunal-ileal bypass
(1). Indications for revision included poor weight loss (9),
severe gastroesophageal reflux (7), anastomatic stricture or
intestinal obstruction (6) and failure to thrive (1). Some
patients had multiple indications for surgery. Pre-operative
workup included esophageal manometry, esophageal pH studies,
EGD, and upper GI series in the majority of patients.
Outcomes are reported from an IRB approved prospective
database.
Results: All 20 patients, including 18 women and 2 men,
underwent successful operations. The mean pre-op BMI for
the entire group was 45.7 kg/m2 with a mean reduction of 12%
of BMI. Nine patients underwent revisional surgery for failed
weight loss (BMI >30). All nine patients had prior gastroplasty.
Seven patients underwent revision for severe gastroesophageal
reflux. Preoperatively, all had normal esophageal
manometry studies and abnormal esophageal pH studies. Five
patients have complete resolution of symptoms while two
patients have occasional breakthrough symptoms requiring
intermittent anti-reflux medications. Five patients underwent
either revision of an anastomatic stricture, alleviation of an
internal hernia, or lysis of adhesions for obstructive systems.
One patient underwent reversal of a jejunal ileal bypass for
failure to thrive. Most patients in the series had a RYGB as the
revisional surgery. Complications include ventral hernia (1),
wound infection (1) and splenic injury (1). There were no anastomotic
leaks in our group.
Conclusion: When weight loss is inadequate or complications
occur after bariatric surgeries, we found that RYGB is an effective
revisional procedure. Surgeons must have a thorough
knowledge of the various surgical techniques employed, both
past and present, in order to deal with their complications.
P088–Bariatric Surgery
AVOIDANCE OF SELECTIVE COINCIDENT CHOLECYSTECTO-
MY IN PATIENTS UNDERGOING LAPAROSCOPIC BARIATRIC
SURGERY, Andras Sandor MD, Donald R Czerniach MD,Patrick
McEnaney MD,Liam Haveran DO,Richard A Perugini
MD,Demetrius E.M. Litwin MD,John J Kelly MD, Department of
Surgery, UMASS Memorial Medical Center, Worcester, MA,
USA
The association between rapid weight loss after bariatric surgery
and the development of cholelithiasis is well established.
Simultaneous laparoscopic cholecystectomy (LC) coincident
with laparoscopic Roux-en-Y gastric bypass (LGBP) has been
advocated but can be technically challenging. Our objective
was to evaluate the risk associated with avoiding simultaneous
LC in bariatric patients either with negative or positive preoperative
US for the presence of gallstones.
Prospectively collected data in a tertiary care academic medical
center entered into a patient database was retrospectively
reviewed. 268 consecutive pts underwent LGBP for morbid
obesity between 6/30/99 and 10/30/02. Pts with previous cholecystectomy
(n=71) were excluded from the study. All pts with
intact gallbladder had preoperative transabdominal US to rule
out cholelithiasis. Patients were divided to two groups. In
Group I (6/30/99 ? 11/25/01) all pts with a positive preoperative
US underwent selective LC coincident with the LGBP. In Group
II (11/26/01 ? 10/30/02) all pts were treated conservatively
regardless of the preoperative US result. Patients in Group II
with symptomatic cholelithiasis at the time of surgery (n=1)
underwent coincident LC and were excluded from the followup.
In Group I (n=123) 26 pts with a positive US underwent selec-
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