Outcomes of primary versus revisional robotically assisted laparoscopic Roux-en-Y gastric bypass: a multicenter analysis of ten-year experience.

BACKGROUND: Postoperative morbidity after laparoscopic bariatric surgery is considered higher for patients undergoing revisional versus primary procedures. The objective of this retrospective cohort study was to compare outcomes between patients undergoing primary versus revisional robotically assisted laparoscopic (RAL) Roux-en-Y gastric bypass (RYGB). METHODS: Data of all patients who underwent RAL primary and revisional RYGB between 2009 and 2019 at two accredited, high-volume bariatric surgery centers-the Memorial Hermann - Texas Medical Center, Houston, TX, and the Tower Health, Reading Hospital, Reading, PA, were analyzed. Primary outcomes were early (< 30 days) and overall postoperative complications. Secondary outcomes included intraoperative complications, operative times, conversions to laparotomy, length of hospital stay, early (< 30 days) postoperative readmissions and deaths. RESULTS: Data of 1072 patients were analyzed, including 806 primary and 266 revisional RAL RYGB procedures. Longer operative times (203 versus 154 min, P < 0.001), increased number of readmissions for oral intolerance (10.5% versus 6.7%, P = 0.046) and higher rate of gastrojejunal stricture (6.4% versus 2.7%, P = 0.013) were found in the revisional group. Gastrointestinal leak rates were 0.2% for the primary versus 1.1% for the revisional group (P = 0.101). Early (< 30 days) reoperations rates were 2.2% for the primary versus 1.1% for the revisional group (P = 0.318). There were no statistically significant differences between groups in overall and severe complication rates. CONCLUSION: Patients undergoing RAL primary and revisional RYGB had comparable overall outcomes, with a non-significant higher early complication rate in the revisional group. Despite the study being underpowered to detect differences in specific complication rates, the morbidity seen in the revisional RYGB group remains markedly below literature reports of revisional laparoscopic RYGB and might suggest a benefit of robotic assistance. Further prospective studies are needed to confirm these results.

Early postoperative small bowel obstruction: A review.

Early postoperative small bowel obstruction (ESBO) is a challenging problem. Although it is usually amenable to non-operative management, a significant proportion of patients will require re-operation. Certain causes of ESBO and types of index procedures should prompt consideration for early re-operation. A laparoscopic approach during the index operation, certain barrier agents and closure of mesenteric defects in bariatric surgery may reduce the risk of ESBO. There is no consensus regarding an acceptable length of time for initial non-operative management of ESBO but re-operation beyond two weeks may be associated with increased complications.

Robot-assisted versus laparoscopic gastric bypass: comparison of short-term outcomes.

BACKGROUND: Roux-en-Y gastric bypass is an effective treatment for severe obesity and obesity-related comorbidities. Presently, gastric bypass is performed most often laparoscopically, although a robotic-assisted procedure is the preferred approach for an increasing number of bariatric surgeons. METHODS: This retrospective study compared the results of 100 Roux-en-Y gastric bypass operations using the da Vinci robot and 100 laparoscopic Roux-en-Y gastric bypasses performed laparoscopically. Short-term outcomes were determined by evaluating mortality, length of stay, length of operation, return to the operating room within 90 days of operation, conversions to open procedure, leaks, strictures, transfusions, and hospital readmissions. RESULTS: There was no mortality, pulmonary embolus, or conversion to open procedure in either group. Both the laparoscopic and robotic operative times decreased progressively, although the robotic operation time was longer (mean, 144 versus 87 min, P < 0.001). The length of stay was shorter for the robotic-assisted group (37 versus 52 h, P < 0.001), and 60% of these patients were discharged after one night's stay (P < 0.001). There were fewer transfusions (P = 0.005) and readmissions (P = .560) in the robotic group. The stricture rate was higher in the first 50 robotic procedures (17 mm gastrotomy) but resolved in the second 50 procedures (21 mm gastrotomy). There was no difference in the rate of leak and return to the operating room between groups (both P > 0.05). CONCLUSIONS: These results indicate that Roux-en-Y gastric bypass can be performed safely with robotic assistance, even during the first 100 cases.

The effect of tissue compression on circular stapler line failure.

BACKGROUND: Anastomotic leak after gastrointestinal anastomosis is a well-known and serious complication, yet there is no standardized approach to reliably create an anastomosis with sufficient mechanical properties to consistently avoid an anastomotic leak. The purpose of this study was to evaluate the relationships among combined tissue thickness, tissue compression, closed staple limb length, and mechanical strength of an anastomosis created with a circular stapler, as measured by maximum intraluminal pressure obtained at the time of leakage. METHODS: Using 27 porcine stomachs and 27 porcine small-intestine segments, we measured tissue thickness and assessed the tissue compression at three different anvil closure distances created by a circular stapling device. Maximum intraluminal pressure was determined by infusing colored water into the porcine materials and increasing the pressure until leakage from the anastomosis occurred. RESULTS: Tissue compression increased as the closure distance narrowed between the anvil and circular stapler (p < .0001). A tissue compression of ≥6 PSI correlated strongly with a maximum intraluminal pressure of ≥18 mmHg (43% for <6 PSI vs. 90% for ≥6 PSI; p = .02); tissue compression ≥12 PSI was necessary to obtain an acute maximum intraluminal pressure of ≥22 mmHg in 13 of 15 of our samples (p = .04). CONCLUSIONS: Maximum intraluminal pressure of an anastomosis in this porcine model correlated most strongly with the compression of the tissue involved in the anastomosis. This experimental model provides a framework for constructing a systematic approach to creating an anastomosis with sufficient mechanical strength. However, this study was not intended to establish the upper range of tissue compression beyond which a permanent tissue injury may occur.