One-year readmission rates at a high volume bariatric surgery center: laparoscopic adjustable gastric banding, laparoscopic gastric bypass, and vertical banded gastroplasty-Roux-en-Y gastric bypass.

BACKGROUND: An increasing importance has been placed on a bariatric program's readmission rates. Despite the importance of such data, there have been few studies that document 1-year readmission rates. There have been even fewer studies that delineate the causes of readmission. The objective of this study is to delineate the rates and causes of readmissions within 1 year of bariatric operations performed in a high-volume center. METHODS: Records for all patients undergoing bariatric operations during a 31-month period were harvested from the hospital electronic medical database. Readmissions for these patients were then identified within the hospital database for the year following the index operation. The electronic medical records of all readmitted patients were reviewed. RESULTS: The overall 1-year readmission rate for 1,939 consecutive bariatric operations was 18.8%. The laparoscopic adjustable gastric band (LAGB) had the lowest readmission rate of 12.69%. Next was the vertical banded gastroplasty-Roux-en-Y gastric bypass (VBG-RYGB) with a rate of 15.4%. The laparoscopic Roux-en-Y gastric bypass (LRYGB) had the highest readmission rate of 24.2%. Leading causes of readmission were abdominal pain with normal radiographic studies and elective operations. Independent factors predicting readmission were found to be LOS > 3 days (odds ratio 1.69 p = 0.004) and having a LRYGB (odds ratio of 1.49 p = 0.003). The previously reported reoperation rate for bowel obstruction of 9.7% had decreased to 3.7% due to changes in operative technique. CONCLUSION: Rates of readmissions for patients undergoing bariatric surgery center at our high-volume center decreased over time and are comparable to other major abdominal operations.

An analysis of gastric pouch anatomy in bariatric surgery.

BACKGROUND: The goal of most bariatric surgeons has been to construct small volume pouches in the proximal stomach to restrict the intake of food. The purpose of this study is to demonstrate that in addition to pouch volume, specific gastric pouch anatomy plays a significant role in weight loss. MATERIALS AND METHODS: The physical properties and dynamics of the pouch in our form of gastric bypass were compared with those in the most commonly performed bariatric procedures by creating a model. Our weight loss data were reviewed and compared with data reported in the literature. RESULTS: According to LaPlace's and Poiseulle's Laws, a long narrow cylinder will have less wall tension and slower flow rate of material than a wider cylinder. Bariatric procedures with narrow pouches appear to produce better weight loss. CONCLUSIONS: Long narrow pouches should have less tendency to enlarge and should delay the transit of material to a greater degree than wider pouches according to the LaPlace's and Poiseuille's Laws. Our data and the data of others strongly suggest that long narrow pouches are the most effective operations in bariatric surgery.

Reducing the incidence of incisional hernias following open gastric bypass surgery.

BACKGROUND: Abdominal wall hernias are a common complication following open gastric bypass (RYGBP) surgery. In an effort to reduce the incidence of incisional hernias with our form of open RYGBP, progressively smaller, upper midline epigastric incisions have been utilized along with permanent sutures. The purpose of this study is to analyze whether incision location, size and choice of suture material affect the incidence of incisional hernias following open RYGBP. METHODS: Clinically evident incisional hernias and other wound complications and non-wound related complications were analyzed for 1,180 consecutive primary open proximal RYGBP procedures performed between August 2002 and June 2006. Progressively smaller, upper midline incisions were utilized during the time period of the study. RESULTS: Smaller incisions limited to the upper abdomen and approximated with permanent sutures were associated with significantly fewer hernias (P<0.01), wound dehiscences (P<0.03), eviscerations (P<0.03) and wound infections (P<0.03). Smaller incisions may also be associated with less postoperative discomfort. CONCLUSION: A reduction in incision size, the avoidance of the periumbilical region and the use of nonabsorbable sutures has significantly reduced the incidence of incisional hernias and acute fascial disruptions with our form of open RYGBP. These findings are consistent with LaPlace's law regarding wall tension and vessel radius. In addition, we found smaller incisions to be associated with fewer infections and seromas and less postoperative discomfort. A reduction in incision size has not been associated with an increase in morbidity or mortality or changes in the operative time.

Bowel obstruction after open and laparoscopic gastric bypass surgery for morbid obesity.

BACKGROUND: Bowel obstruction is increasingly recognized as an important complication after gastric bypass. This study analyzed late bowel obstruction after open and laparoscopic gastric bypass surgery. STUDY DESIGN: The medical records of 1,378 patients who had proximal gastric bypass during the years 2002 and 2003 at a large bariatric center were evaluated for readmission with bowel obstruction requiring operations. In the study group, 697 patients underwent a laparoscopic approach and 735 had an open approach to gastric bypass. Patients had a minimum followup of 18 months. RESULTS: In the laparoscopic group, 68 of the 697 patients were readmitted for bowel obstruction requiring operations, for an incidence of 9.7%. There were 14 additional recurrent obstructions, for a total of 82 operations. Of the 68 patients requiring reoperations, 3 (4.4%) required bowel resection and 8 (11.7%) had conversion to an open approach. Bowel resections were performed in two of the three patients with a second episode of bowel obstruction. The average time intervals between the primary operation in 2002 and 2003 and the first episode of obstruction were 511 and 385 days, respectively. There were no readmissions requiring operations for late bowel obstruction in the open gastric bypass group. CONCLUSIONS: We found an unanticipated high incidence of bowel obstruction after laparoscopic gastric bypass surgery. There were no hospital admissions for bowel obstruction requiring operations in the open gastric bypass group. Lack of adhesions and the resulting free displacement of small bowel after laparoscopy appear to be the cause of this complication. Open gastric bypass surgery produces thin, diffuse upper abdominal adhesions that may then stabilize the bowel and prevent internal hernias and bowel obstruction. An open approach may be a reasonable option for management of recurrent episodes of bowel obstruction after laparoscopy.