Procedural Changes to Decrease Complications in Laparoscopic Gastric Bypass

Abstract

Background and Objectives:Laparoscopic Roux-en-Y gastric bypass (LRYGB) is a complex procedure performed in a patient population with significant medical comorbidities. Evaluation and modification of surgical techniques can minimize the complications associated with the lengthy learning curve for this procedure. The purpose of this study was to evaluate a single surgeon's decade-long experience with LRYGB, to determine whether complications decreased with experience and surgical modifications improved perioperative outcomes.Methods:A retrospective review of all procedures performed by a fellowship-trained surgeon (MK) from December 1, 2000, to October 31, 2013, identified patients who underwent LRYGB. We evaluated perioperative outcomes in 1117 patients and examined the impact of modification of surgical techniques on complications. The patients were divided into 4 groups: cases 1–100 (group 1), cases 101–400 (group 2), cases 401–700 (group 3), and cases 701-1117 (group 4).Results:Operating time decreased significantly after the initial 100 cases, from 179.1 minutes for group 1 to 122.1 minutes for group 4. With experience, early complication rates improved from 25.0% to 5.0%, but the rates of early reoperation increased from 1.0% to 2.2% over the 4 case groups. Late complication and reoperation rates increased from 4.0% to 10.5%. However, rates of bleeding, early stricture, internal hernia, and wound infection all decreased after the modification of surgical techniques.Conclusions:Operating time and early complication rates decreased with operative experience, but late complication and early and late reoperation rates increased. However, after modifications of surgical technique, common complications of LRYGB decreased to rates lower than those reported in several gastric bypass case series in the literature. The findings in this study will be helpful to fellow bariatric surgeons who are refining their strategies for reducing morbidity related to LRGYB.

Clinical Practice Guidelines For The Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures – 2019 Update: Cosponsored By American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society For Metabolic & Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists

“…Another study of robotassisted RYGB found 100 cases on the learning curve to be a discriminator in terms of operative time but without any differences in outcomes or complications (371). This 100-case mark was also reported in a study by Beitner et al (372) for RYGB, in which late complication and re-operation rates were eventually improved with modification in surgical technique. In a Chinese study of patients undergoing RYGB, the learning curve was more associated with operating time and morbidity than mortality or amount of eventual weight loss (373).…”

Clinical Practice Guidelines for the Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures – 2019 Update: Cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic and Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists

“…This 100‐case mark was also reported in a study by Beitner et al for RYGB, in which late complication and re‐operation rates were eventually improved with modification in surgical technique. In a Chinese study of patients undergoing RYGB, the learning curve was more associated with operating time and morbidity than mortality or amount of eventual weight loss . However, Rausa et al found that the relative superiority of LRYGB over open RYGB may be due to extended learning curves in the former.…”

Surgical trainee impact on bariatric surgery safety

“…Laparoscopic RYGB is a complex procedure that requires advanced skills and understandings of key surgical steps [28]. In our study, fellow participation during laparoscopic RYGB was associated with an increased risk of developing complications when compared to non-trainees.…”