Surgical weight loss >65 years old: is it worth the risk?

BACKGROUND: Weight loss surgery in patients >65 years old has been underused, secondary to the morbidity and mortality concerns of healthcare providers. Comparative outcomes analyses of this patient population have been lacking. The purpose of the present report was to evaluate the safety and outcome of gastric bypass in patients >65 years of age. METHODS: A prospective database was used to analyze the safety, operative morbidity, and outcome. All patients undergoing surgery since January 2005 were included. RESULTS: The analysis of 1474 patients demonstrated a greater operative risk profile for patients >65 years (n = 100) compared with those <65 years old (n = 1374) related to sleep apnea (45% versus 34%), diabetes mellitus (65% versus 33%), and hypertension (81% versus 57%). The operative outcomes were similar for the 2 groups as determined by the operative time (70 versus 65 minutes), length of stay (1.97 versus 1.3 days), and 30-day readmission rate (6.0% versus 7.4%). The postoperative complication rates were low in the patients >65 years old (bleeding 1.0%, pulmonary 3.0%, cardiac 2.0%, wound 2.0%, and 30-day mortality rate 0%). The percentage of excess body weight loss in the gastric bypass patients was similar between the patients >65 years old and those <65 years old at 12 months (74.8% versus 77.8%) and 24 months (83.4% versus 78.5%). CONCLUSION: Our experience represents one of the largest series of laparoscopic gastric bypass in elderly patients. The data have demonstrated excellent outcomes compared with a younger population.

Advanced laparoscopic skills decrease the learning curve for laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: The reported learning curve for laparoscopic Roux-en-Y gastric bypass (LRYGB) is 20-100 cases. Our aim was to investigate whether advanced laparoscopic skills could decrease the learning curve for LRYGB with regard to major morbidity. METHODS: The senior author performed all operations in this series. His training included a laparoscopic fellowship without bariatric surgery, six years in surgical practice focusing on upper abdominal laparoscopic surgery, two courses on bariatric surgery at national meetings, one week of observing a bariatric program, and two mentored LRGBY cases. A comprehensive obesity program was put in place before the program began. Data were collected prospectively and reviewed at the series' end. Results are presented as mean +/- standard deviation and standard statistical analysis was applied. RESULTS: Between December 2003 and February 2005, 107 LRYGB operations were performed. Mean operative time decreased significantly with experience (p < 0.0001) and was 154 +/- 29, 132 +/- 40, 127 +/- 29, and 114 +/- 30 min by quartile. Mean length of stay was 2.9 +/- 1.6 days. Mean excess weight loss was 45.3% (n = 41) at six months. There were no conversions to an open procedure, no anastomotic leaks, no pulmonary embolisms, and no bowel obstructions. The five major complications (3 in the first 50 and 2 in the last 57 cases, p = NS) were two cases of biliopancreatic limb obstruction, two cases of significant gastrointestinal bleeding from anastomotic ulcer, and one case of gastric volvulus of the remnant stomach. CONCLUSIONS: A bariatric fellowship and/or extended mentoring are not required to safely initiate a bariatric program for surgeons with advanced laparoscopic skills. Operative time decreases significantly with experience, but morbidity and mortality remain low even early in the learning curve. A comprehensive obesity program seems necessary for success.

Laparoscopic surgery for morbid obesity: 1,001 consecutive bariatric operations performed at The Bariatric Institute, Cleveland Clinic Florida.

BACKGROUND: Morbid obesity is an epidemic in America. This series evaluates the safety and efficacy in the first 1,001 laparoscopic bariatric operations performed at The Bariatric Institute, Cleveland Clinic Florida. METHODS: A retrospective review was conducted examining all patients undergoing a primary bariatric procedure (either laparoscopic gastric bypass or laparoscopic gastric banding) from July 2000 to December 2003. RESULTS: 2 surgeons performed 1,001 laparoscopic bariatric operations. Average age was 47 (19-75) years, average BMI was 55.6 (35-97) kg/m2, and average ASA class was III. Excess weight loss was 51% at 6 months, 73.4% at 1 year for the gastric bypass group and 54% at 1 year for the laparoscopic banding group. The overall complication rate was 31.8% (12.4% major and 19.4% minor) in the gastric bypass group and 13% in the laparoscopic banding group. There was no postoperative mortality. CONCLUSION: Laparoscopic bariatric surgery is feasible and safe for weight loss. Results obtained have been comparable to those reported for the open approach for weight loss, with a similar major morbidity rate and an improved mortality rate.

Laparoscopic-assisted peritoneal dialysis catheter placement, an improvement on the single trocar technique.

In 2002, Ochsner laparoscopic surgeons and nephrologists began placing peritoneal dialysis (PD) catheters via a laparoscopic-assisted method. We compared laparoscopically placed PD catheters (LAPD) with catheters most recently placed without laparoscopic aid (STPD). The method for this study is a retrospective chart review. Demographics of both groups were similar. Nine of 20 (45%) in the STPD group and 16 of 23 (70%) in the LAPD group had had previous abdominal surgery. Three of 20 (15%) of STPD had complications, including one small bowel injury. Four of 23 (17.4%) of the LAPD had complications. One of 20 (5%) in the STPD group and 3 of 23 (13%) in the LAPD group had dialysate leaks. In the STPD group, 8 of 20 (40%) had catheter problems that led to removal in 7 (35%). In the LAPD group, 6 of 23 (26%) had catheter malfunction: 3 were salvaged with a laparoscopic procedure; 3 (13%) were removed for malfunction. 1) LAPD allows proper PD placement after complex abdominal surgery; 2) Although dialysate leak complications are increased, bowel perforation risk is less; 3) Because of proper placement, PD catheter malfunction rate is less with LAPD; 4) Although no results obtained statistical significance, we found LAPD superior to STPD and have converted to this technique.