Narcotic withdrawal syndrome following gastric bypass--a difficult diagnosis.

BACKGROUND: It is common for bariatric patients to experience postoperative nausea, depression and remorse for several months following surgery. Difficulty exists for the surgeon in delineating the physical from the psychological in treating these patients. Preoperative education, evaluation and preparation, although essential, will not identify nor eliminate all potential problems. METHODS: We report the case history of a patient who ultimately underwent reversal of her gastric bypass. Her symptoms required multiple procedures and hospital admissions for what appeared to be anatomical problems. All procedures were done laparoscopically. RESULTS: The patient's main complaints of persistent nausea and abdominal pain combined with radiographic evidence of sub-optimal anatomic construct led to multiple operative procedures. Psychological intervention relative to the persistent nausea and abdominal pain was ineffectual, although the supportive and consistent nature of the psychotherapy relationship was useful in overall patient stability and emotional well being. Complete reversal of the bypass did not effect improvement. Ultimately, the diagnosis of narcotic withdrawal prompted the institution of methadone treatment with complete cessation of the symptoms of nausea and pain. CONCLUSIONS: The diagnosis of narcotic withdrawal syndrome can be difficult in the postoperative bariatric patient. Psychological evaluation and support are essential elements of the program throughout the entire course of a patient's treatment experience. Laparoscopic techniques simplified the surgical care of this patient.

Laparoscopic Roux-en-Y gastric bypass: technique and 3-year follow-up.

BACKGROUND: The purpose of this study is to evaluate our experience with the laparoscopic gastric bypass. The technique, weight loss data, and complications are described. METHODS: 1,500 consecutive patients were evaluated prospectively. All patients met NIH criteria for bariatric surgery. Although there have been modifications with respect to staplers, suture material, and dissection techniques, the basic anatomical construct has remained the same, including performing a completely hand-sewn gastrojejunostomy. RESULTS: There were no anastomotic leaks from the hand-sewn gastrojejunostomy. Operative times now are consistently 60 minutes or less, although the learning curve is quite long. Average hospital stay was 1.5 days. Average excessive weight loss was 69% at one and two years and 62% at three years. Overall complication rate was 14.8%. Perioperative death rate was 0.2%. CONCLUSIONS: The laparoscopic gastric bypass is a viable alternative to traditional open techniques. It is as safe and effective and can be performed with equal or greater efficiency. Adoption of hand-suturing techniques helps to improve the surgeon's skill and ability to cope with the occasional stapler misfire or complication.

Laparoscopic Roux-en-Y gastric bypass for morbid obesity: technique and preliminary results of our first 400 patients.

HYPOTHESIS: A technique of the laparoscopic Roux-en-Y gastric bypass can be developed that is safe, effective, and practical in the community setting. DESIGN: A case series of 400 morbidly obese and superobese individuals who underwent the laparoscopic Roux-en-Y gastric bypass over a 22-month period. SETTING: Community private practice in Fresno, Calif. PATIENTS: A consecutive sample of 400 patients (70 males and 330 females) who met National Institutes of Health criteria for recommendation of a bariatric procedure. Only patients who had a previous gastric or bariatric procedure were excluded from this sample. INTERVENTION: Laparoscopic Roux-en-Y gastric bypass with a hand-sewn gastrojejunal anastomosis. MAIN OUTCOME MEASURES: Weight loss, complications, length of hospital stay, successful completion of the operation, and operative times were measured. RESULTS: Open conversion was required in 12 patients (6 males and 6 females) and a secondary operation for incomplete division of the stomach was required in 2 patients early in the case series. Alternative exposure and fixation techniques greatly reduced these occurrences. There were 6 staple-line failures owing to a change in the manufacture of the instrument. There were no leaks at the gastrojejunal anastomosis, but 21 patients required endoscopic balloon dilation for significant stenosis. The average hospital stay was 1.6 days for the patients who underwent laparoscopy and 2.7 days for patients requiring open conversion. Average excessive weight loss was 69% at 12 months. Operative times are between 60 and 90 minutes. Other complications are described. CONCLUSION: The Roux-en-Y gastric bypass can be safely and effectively performed in the community setting using advanced laparoscopic techniques.

Complications of the laparoscopic Roux-en-Y gastric bypass: 1,040 patients--what have we learned?

BACKGROUND: The Roux-en-Y gastric bypass (RYGBP) is one of the most common operations for morbid obesity. Laparoscopic techniques have been reported, but suffer from small numbers of patients, longer operative times and seemingly higher initial complication rates as compared to the traditional "open" procedure. The minimally invasive approach continues to be a challenge even to the most experienced laparoscopic surgeons. The purpose of this study is to describe our experience and complications of the laparoscopic Roux-en-Y gastric bypass with a totally hand-sewn gastrojejunostomy. METHODS: 1,040 consecutive laparoscopic procedures were evaluated prospectively. Only patients who had a previous open gastric procedure were excluded initially. Eventually, even patients with failed "open" bariatric procedures and other gastric procedures were revised laparoscopically to the RYGBP. All patients met NIH criteria for consideration for weight reductive surgery. RESULTS: There were no anastomotic leaks from the hand-sewn gastrojejunostomy. Early complications and open conversions were related to sub-optimal exposure and bowel fixation techniques. Several staple failures were attributed to a manufacturer redesign of an instrument. Average hospital stay was 1.9 days for all patients and 1.5 days for patients without complications. Operative times consistently approach 60 minutes. Average excess weight loss was 70% at 12 months. There were 5 deaths: perioperative pulmonary embolism (1), late pulmonary embolism (2), asthma (1), and suicide (1). CONCLUSIONS: The laparoscopic Roux-en-Y gastric bypass for morbid obesity with a totally hand-sewn gastrojejunostomy can be safely performed by the bariatric surgeon with advanced laparoscopic skills in the community setting. Fixation and closure of all potential hernia sites with non-absorbable sutures is essential. Stenosis of the hand-sewn gastrojejunal anastomosis is amenable to endoscopic balloon dilation. Meticulous attention must be paid to the operative and perioperative care of the patient.