Does the position of the alimentary limb in Roux-en-Y gastric bypass surgery make a difference?

Intestinal obstruction and other complications have been reported following Roux-en-Y gastric bypass (RYGB) surgery. There is controversy of whether the alimentary limb should be placed in the retrocolic or antecolic position. A retrospective analysis was performed on 444 patients undergoing RYGB surgery for morbid obesity during a six year period. During operation, the surgeon chose the positioning of the 75-cm alimentary limb based upon technical consideration (the presence of adhesions from prior surgical procedures, thickness of the transverse mesocolon and mobility of the small bowel mesentery). Group A (216) patients had placement of the Roux limb anterior to the transverse colon, and group B (228) patients had placement of the limb through an opening created in the transverse mesocolon. The average age was 40 years (range 19-64) and the body mass index ranged from 40 to 75 kg/m2. Patients were followed for 24-86 months (mean 36 months). Any patients lost to follow-up were excluded. The average age of patients in the study was 40 years (range 19-64 years). Patients in both groups were similar in their body mass index and demographic characteristics. Group A had 16 patients (7.4%) that had early intolerance to enteral intake, compared to 13 patients in group B (5.7%, P>0.05). Thirteen patients required reoperation for intestinal obstruction (seven patients in group A and six patients in group B (P>0.05). Development of anastomotic stricture occurred in one patient (0.5%) in group A and three patients (1%, P>0.05) in group B. There were no differences in mean operating room times, hospital length of stay, and excess weight lost. No other complications during the follow-up period were attributed to the position of the alimentary limb. Placement of the Roux limb in the antecolic position is may be technically more feasible in some patients and does not appear to be associated with more complications. It avoids the risk of an internal hernia through the transverse and does not appear to be associated with feeding difficulties in the early or late postoperative period.

Outcome and complications of gastric bypass in super-super obesity versus morbid obesity.

BACKGROUND: Roux-en-Y gastric bypass (RYGBP) reduces the co-morbidities of obesity. Patients with super-super obesity (BMI>or=60) present additional technical and medical challenges. This study compares the results in super-super-obese patients with patients with a BMI of <60 over a 5.5-year period. METHODS: Retrospective analysis was performed of the 504 patients who underwent open RYGBP from January 1999 through June 2004. Patients were divided into 2 groups: Group A (444 patients) had a BMI <60, and Group B (60 patients) had a BMI>or=60, and also had a greater percentage of males. The groups were otherwise similar in demographics and co-morbidities. RESULTS: Concomitant ventral herniorrhaphy was performed in 23 patients (5%) in Group A and in 3 patients (5%) in Group B. Concomitant cholecystectomy was done in 11.2% in Group A and 10% in Group B. Group A patients had an incidence of leaks of 1.3%, and there were no leaks in Group B. Wound infection rate for Group A was 5% vs 1.7 % in Group B (NS). Mortality for both groups was similar. The stricture rate for Group A was 0.9% compared with 1.7 % for Group B. After 1 year, excess weight lost was 41.7% in Group A and 38.3% in Group B. The development of anemia was not statistically different (8.3% vs 11.0 %). Incidence of postoperative gallbladder disease and incisional hernia was similar. CONCLUSIONS: Super-super-obese patients should not be excluded from RYGBP because of a perceived increased risk based upon BMI.