A novel technique for fascial fixation of laparoscopic adjustable gastric band ports.

Access port dislodgement after laparoscopic adjustable gastric banding is a recurring problem that often requires operative revision. Securing the port to the abdominal wall fascia in the traditional way with standard instruments is challenging in obese patients due to a thick abdominal wall. Therefore, we have devised a novel and simple technique for access port fixation using the EndoStitch device.

The learning curve for laparoscopic Roux-en-Y gastric bypass is 100 cases.

BACKGROUND: The purpose of this study was to determine the effect of operative experience on perioperative outcomes for laparoscopic Roux-en-Y gastric bypass (LGB). METHODS: Between July 1997 and September 2001, 750 patients underwent LGB for the treatment of morbid obesity at our center. We evaluated the perioperative outcomes of the first 150 consecutive patients to determine if a learning curve effect could be demonstrated. The patients were divided into three groups (1, 2, and 3) of 50 consecutive patients, and outcomes for each group were compared. RESULTS: The patients in group 3 had a larger body mass index (BMI), were more likely to have had prior abdominal surgery, and were more likely to have secondary operations at the time of LGB. Operating time decreased from a mean of 311 min in group 11 to 237 min in group 3, and technical complications were reduced by 50% after an experience of 100 cases. CONCLUSIONS: Operative time and technically related complications decreased with operative experience even though heavier patients and higher-risk patients were more predominant in the latter part of our experience. LGB is a technically challenging operation with a long learning curve. To minimize morbidity related to the learning curve, strategies for developing training programs must address these challenges.

Symptomatic improvement in gastroesophageal reflux disease (GERD) following laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: The purpose of this study was to determine the effect of laparoscopic Roux-en-Y gastric bypass (LRYGBP) on symptomatic control of gastroesophageal reflux disease (GERD). METHODS: Morbidly obese patients (n = 435) who underwent LRYGBP for morbid obesity were assessed for changes in GERD symptoms, quality of life, and patient satisfaction after surgery. RESULTS: A total of 238 patients (55%) had evidence of chronic GERD, and 152 patients (64%) voluntarily participated in the study. The mean body mass index (BMI) was 48 kg/m2. The mean excess weight loss was 68.8% at 12 months. There was a significant decrease in GERD-related symptoms, including heartburn (from 87% to 22%, p<0.001); water brash (from 18% to 7%, p<0.05); wheezing (from 40% to 5%, p<0.001) laryngitis (from 17% to 7%, p<0.05); and aspiration (from 14% to 2%, p<0.01) following LRYGBP. Postoperatively, the use of medication decreased significantly both for proton pump inhibitors (from 44% to 9%, p<0.001) and for the H2 blockers (from 60% to 10%, p<0.01). SF-36 physical function scores and the mental component summary scores improved after the operation (87 vs 71; p<0.05 and 83 vs 66; p<0.05, respectively). Overall patient satisfaction was 97%. CONCLUSION: LRYGBP results in very good control of GERD in morbidly obese patients with follow-up as late as 3 years. Morbidly obese patients who require surgery for GERD may be better served by LRYGBP than fundoplication because of the additional benefit of significant weight loss.

Laparoscopic resection of a large periadrenal nonmalignant pheochromocytoma.

This is, to our knowledge, the first case description of an extraadrenal pheochromocytoma located in the periadrenal fat. Pheochromocytoma is a tumor that originates in the chromaffin tissue. Extraadrenal pheochromocytomas have been described commonly in locations such as the organ of Zuckerkandle (29%); the bladder (12%); the sacrum, testis, rectum, and pelvic floor (2%); the upper abdomen in association with celiac, superior mesenteric, and inferior mesenteric ganglia (43%); the thorax (12%); and the neck (2%), most commonly in association with the ninth or tenth cranial nerve ganglion. Our patient was a 40-year-old woman known to have had an adrenal mass for the last 4 years. She was referred for surgery because of an increase in the size of the mass to 11 cm. Laparoscopic adrenalectomy was performed via a posterior flank approach. The pathology report was of periadrenal fat pheochromocytoma, with positive staining for synaptophysin, chromogranin, and vimentin. The patient was discharged on postoperative day 3. The unique feature in this case was the uncommon location of the extraadrenal tumor: the supraadrenal fat. The other unique finding in this case was that the pheochromocytoma was neither symptomatic nor malignant, common features of extraadrenal masses.

Outcomes after laparoscopic Roux-en-Y gastric bypass for morbid obesity.

OBJECTIVE: To evaluate the short-term outcomes for laparoscopic Roux-en-Y gastric bypass in 275 patients with a follow-up of 1 to 31 months. SUMMARY BACKGROUND DATA: The Roux-en-Y gastric bypass is a highly successful approach to morbid obesity but results in significant perioperative complications. A laparoscopic approach has significant potential to reduce perioperative complications and recovery time. METHODS: Consecutive patients (n = 275) who met NIH criteria for bariatric surgery were offered laparoscopic Roux-en-Y gastric bypass between July 1997 and March 2000. A 15-mL gastric pouch and a 75-cm Roux limb (150 cm for superobese) was created using five or six trocar incisions. RESULTS: The conversion rate to open gastric bypass was 1%. The start of an oral diet began a mean of 1.58 days after surgery, with a median hospital stay of 2 days and return to work at 21 days. The incidence of early major and minor complications was 3.3% and 27%, respectively. One death occurred related to a pulmonary embolus (0.4%). The hernia rate was 0.7%, and wound infections requiring outpatient drainage only were uncommon (5%). Excess weight loss at 24 and 30 months was 83% and 77%, respectively. In patients with more than 1 year of follow-up, most of the comorbidities were improved or resolved, and 95% reported significant improvement in quality of life. CONCLUSION: Laparoscopic Roux-en-Y gastric bypass is effective in achieving weight loss and in improving comorbidities and quality of life while reducing recovery time and perioperative complications.

Laparoscopic Roux-en-Y gastric bypass: a case report at one-year follow-up.

Surgery is the only treatment for morbid obesity that has been proven to achieve a significant long-term weight loss. The Roux-en-Y gastric bypass procedure has been performed for the treatment of morbid obesity over the past two decades with excellent results. Wound complications and perioperative morbidity remain unresolved problems of the procedure. A laparoscopic approach to this procedure has great potential to minimize the complications of this highly effective technique. We describe a laparoscopically performed Roux-en-Y gastric bypass in a 28-year-old woman with morbid obesity. The technique described here preserves the anatomic construct of the operation but introduces the benefit of the laparoscopic approach.