Laparoscopic Roux-en-Y gastric bypass versus laparoscopic mini gastric bypass in the treatment of obesity: study protocol for a randomized controlled trial.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) is considered the gold standard in bariatric surgery, achieving durable long-term weight loss with improvement of obesity-related comorbidities. Lately, the laparoscopic mini gastric bypass (LMGB) has gained worldwide popularity with similar results to LRYGB in terms of weight loss and comorbidity resolution. However, there is a lack of randomized controlled trials (RCT) comparing LMGB and LRYGB. This article describes the design and protocol of a randomized controlled trial comparing the outcomes of these two bariatric procedures. METHODS/DESIGN: The trial is designed as a single center, randomized, patient and observer blinded trial. The relevant ethics committee has approved the trial protocol. To demonstrate that LMGB is not inferior to LRYGB in terms of excess weight loss (EWL) the study is conducted as a non-inferiority trial with the sample-size calculations performed accordingly. EWL 12 months after surgery is the primary endpoint, whereas 3-year EWL, morbidity, mortality, remission of obesity related comorbidities, quality of life (QOL) and hormonal and lipid profile changes are secondary endpoints. Eighty patients, 18 years or older and with a body mass index (BMI) between 35 and 50 kg/m2 who meet the Swiss guidelines for the surgical treatment of morbid obesity will be randomized. The endpoints and baseline measurements will be assessed pre-surgery, peri-surgery and post-surgery (fixed follow up measurements are at discharge and at the time points 6 weeks and 12 and 36 months postoperatively). DISCUSSION: With its 3-year follow up time, this RCT will provide important data on the impact of LMGB and LRYGB on EWL, remission of comorbidities, QOL and hormonal and lipid profile changes. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02601092 . Registered on 28 September 2015.

Intraoperative Patterns of Gastric Microperfusion During Laparoscopic Sleeve Gastrectomy.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) has become a very popular surgical treatment for the treatment of morbidly obese patients. Staple line leaks are the major cause of severe morbidity. Reasons for leaks might be hyperpressure (mechanical theory) or hypoperfusion (vascular theory) of the narrow gastric tube. This study assessed microperfusion patterns of the stomach during LSG using visible light spectroscopy (VLS), a method to measure tissue oxygenation (saturated O2 (StO2)). METHODS: The study population comprised 20 patients undergoing LSG. Real-time intraoperative microperfusion measurements were performed at nine different ventral stomach localizations in the antrum, body, and fundus at the beginning of the operation, after mobilization of the greater curve and after sleeve resection. RESULTS: There were 17 women and 3 men, mean age 42.9 years, mean BMI 45.6 kg/m2. There were no staple line leaks. StO2% values dropped substantially in the most cephalad area of measurement at the greater curve after mobilization (56 versus 49 %) and after resection (60 versus 49.5 %). The reduction in StO2 in the most cephalad area from before mobilization of the stomach to resection was 9.5 % (p < 0.01). CONCLUSION: Assessment of microperfusion patterns of the stomach during LSG using VLS is safe and efficacious to use allowing an accurate measurement of StO2%. The upper third of the stomach is the zone of reduced microperfusion with a significant drop of tissue oxygenation after sleeve resection of the stomach.

Primary non-closure of mesenteric defects in laparoscopic Roux-en-Y gastric bypass: reoperations and intraoperative findings in 146 patients.

BACKGROUND: Internal hernias (IH) after laparoscopic Roux-en-Y gastric bypass (LRYGB) have been reported with an incidence of 11 %. IH can lead to bowel incarceration and potentially bowel necrosis. The aim of this study was to analyze reoperations and intraoperative findings in a cohort of patients with unclosed mesenteric defects. METHODS: From a prospective database of patients with LRYGB, we selected as primary cohort patients with non-closure of mesenteric defects and abdominal reoperation for analysis. The data included pre-, intra- and post-operative findings, computed tomogram results and laboratory test results. This group underwent a very very long limb LRYGB, at that time the institutional standard technique. Additionally, a more recently operated cohort with primary closure of mesenteric defects was also analyzed. RESULTS: We identified 146 patients with primary non-closure and reoperation, mean age of 43.8 years. The main indication for reoperation was unclear abdominal pain in 119 patients with 27 patients undergoing a reoperation for other reasons (weight regain, prophylactic surgical inspection of mesenteric defects). Median time and mean excess weight loss from RYGB to reoperation were 41.1 months and 62.7 %, respectively. The incidence of IH was 14.4 %, with all patients with an IH being symptomatic. Conversion rate from laparoscopic to open surgery was 5.5 %, mortality 0.7 % and morbidity 3.4 %. Thirty-one patients underwent a second re-look laparoscopy. Eleven patients had recurrent open mesenteric defects. Three hundred and sixteen patients who underwent primary closure of the mesenteric defects had a reoperation rate of 13.6 % and an IH rate of 0.6 %. CONCLUSION: The incidence of IH in patients without closure of mesenteric defects and reoperation is high and substantially higher compared to patients with primary closure of mesenteric defects. Patients with or without closure of mesenteric defects following LRYGB with acute, chronic or recurrent pain should be referred to a bariatric surgeon for diagnostic laparoscopy.

Effect of a post-operative structured exercise programme on short-term weight loss after obesity surgery using adjustable gastric bands.

BACKGROUND: Exercise has been recommended as an adjunct to diet control to achieve weight loss. No previous studies in the area had formal exercise guidelines or education [1, 2]. Unique to our practice is Bandfit, a personal trainer-led exercise programme for patients following bariatric surgery. METHODS: We analysed the effect of Bandfit on short-term weight loss. A retrospective review of a prospectively collected database of consecutive patients between 2007 and 2008 was undertaken. Patients were educated about appropriate exercises for obese people with active participation. Percentage excess weight loss was calculated at 12 and 36 months. Weights were accepted ±3 months following the gastric banding. Patients were divided into subgroups based on zero, one or greater than one session attended. Patients without available records, 12-month data or a rural address were excluded. Data were statistically analysed utilising a two-sample t test and an analysis of variance (ANOVA) calculation. RESULTS: One hundred sixty-three patients were eligible for inclusion with 26 excluded as described in the methods. In the remaining 137 patients, 49 (36 %) did not attend any sessions, 28 (20 %) attended one, and 60 (44 %) attended more than one session. CONCLUSIONS: Analysis of the %EWL and sessions attended demonstrated a significant difference between those who attended more than one Bandfit session (p < 0.03), compared to those who did not attend any. However, this effect was not seen at 36 months. Attendance at a dedicated educational exercise programme significantly enhances short-term weight loss, but the effect is not seen at 36 months.

Pathologies of the appendix: a 10-year review of 4670 appendicectomy specimens.

BACKGROUND: Debate surrounds the management of the macroscopically normal appendix. Current literature recommends its removal given the high incidence of microscopic appendicitis, and other unusual pathologies in the normal-looking appendix. Negative appendicectomies are reported on the decline with increased use of diagnostic radiological adjuncts. METHODS: This study analysed pathologies of the appendix over 10 years in the Pathology Department in Canberra. A positive appendicectomy was defined as acute appendicitis, faecoliths, worms, endometriosis or appendiceal tumours. We reviewed the positive appendicectomy rate over this time period. RESULTS: There were 4670 appendicectomy specimens in 2386 males (51.1%) and 2284 (49%) females. The incidence of acute appendicitis was 71.3% and the positive appendicectomy rate was 76.3%. There were significantly fewer negative appendicectomies in males (16.8%) compared with females (31.0%). There was no appreciable change in this trend over the study period. Of the positive appendicectomies, there were 129 (3.6%) faecoliths. Of these, only 39.5% had concomitant appendicitis. There were 44 (1.2%) specimens identified with worms. Of these, 40.9% had concomitant appendicitis. There were 14 cases of endometriosis of the appendix of which 36% had concomitant appendicitis. There were 58/3562 (1.6%) appendiceal tumours within the positive appendicectomy group the majority of which were carcinoid tumours (65.5%). CONCLUSION: There is a higher incidence of negative appendicectomies in women compared with men, which is similar to other published studies. Faecoliths and worms are a known cause of appendiceal colic and in our series were identified mostly in the absence of histological evidence of appendicitis.

Outcomes after admission on the day of elective resection for colorectal cancer.

BACKGROUND: When a policy encouraging day of surgery admission (DOSA) was introduced in public hospitals in New South Wales, Australia, there were concerns that patient outcomes would be compromised. The aim of the present study was to compare patients having an elective resection for colorectal cancer (CRC) on a DOSA and a non-DOSA basis in respect of postoperative complications, operative mortality and 2-year survival. METHODS: A comprehensive prospective computerized database is maintained for all patients undergoing a resection for CRC at Concord Hospital, Sydney, Australia. The present study is based on patients who had an elective resection during the transition to DOSA between January 2000 and December 2003. Background characteristics, comorbidity, perioperative factors, tumour pathology, postoperative morbidity and mortality, and overall survival were compared between 274 DOSA and 103 non-DOSA patients. RESULTS: Of the 24 postoperative complications considered there was a significant difference in only four: DOSA patients were less likely than non-DOSA patients to have a respiratory complication (16.1% vs 29.1%, P = 0.004), a prolonged organic confusional state (5.5% vs 23.3%, P < 0.001), acute drug withdrawal (0.4% vs 3.9%, P = 0.021) or multisystem failure (0.4% vs 3.9%, P = 0.021). There was no difference in operative mortality or 2-year survival. CONCLUSION: The present study shows that DOSA did not adversely affect a wide range of outcomes for patients having a resection for CRC. In fact the results suggest that DOSA may protect against respiratory complications and prolonged postoperative confusion.