Initial experience with two-incision laparoscopic adjustable gastric banding.

BACKGROUND: To introduce the 2-incision technique for laparoscopic adjustable gastric banding (LAGB) and report our experience with 25 consecutive patients. Newer applications of minimally invasive laparoscopic techniques have been touted as revolutionary. METHODS: We have introduced a technique for LAGB that uses 2 skin incisions: 1 incision in the right upper quadrant (2.5 cm) that accommodates 2 trocars (11 and 5 mm) through which the dissection and implantation of the band were undertaken, and a 0.5-cm incision in the left upper quadrant for the 5-mm videoscope. The band reservoir was placed in a subcutaneous pocket through the upper quadrant incision. Previously, we used a standard 5-incision technique: 2 in the right upper quadrant, 2 in the left paramedian, and 1 in the subxyphoid area to retract the liver. The data from 25 consecutive 2-incision LAGB procedures (October 2007 to April 2008) were compared with the data from 19 consecutive standard 5-incision LAGB procedures (July 2007 to October 2007). The data are presented as mean +/- SD. The t test was used to compare the mean values, and P <.05 was considered significant. RESULTS: The mean estimated blood loss in the 2-incision LAGB was 54 +/- 2 mL compared with 17 +/- 1 mL in the standard technique (P = .040). The mean operating time for the 2-incision LAGB was 119 +/- 1 minutes compared with 103 +/- 1 minutes for the standard technique (P = .047). No mortality or procedure-related complications (e.g., erosion, slippage) occurred in the 2 groups. CONCLUSION: Two-incision LAGB is feasible; however, it is associated with an increased operating time and blood loss. The operating time and blood loss might improve with standardization of the operative technique and introduction of newly designed flexible tip instruments. Additional prospective studies with a larger sample size are needed to assess the efficacy and benefit of the 2-incision technique versus the standard technique.

Drain amylase levels are an adjunct in detection of gastrojejunostomy leaks after Roux-en-Y gastric bypass.

BACKGROUND: Because anastomotic leaks after gastric bypass surgery can have devastating consequences for the patient, early detection is highly desirable. This and many other bariatric surgical centers have discontinued routine use of upper gastrointestinal contrast x-ray because of the lack of cost-effectiveness, discomfort to the patient, and the failure of the study to detect some leaks. We postulated that drain amylase levels from a juxta-anastomotic drain would detect the presence of salivary amylase and be a sensitive test for gastrojejunostomy leak. STUDY DESIGN: Routine measurement of amylase levels from a drain adjacent to the gastrojejunostomy was instituted in 2005. Leak was defined as anastomotic incompetence documented either by confirmatory upper gastrointestinal contrast x-rays, CT scans, or reoperation. RESULTS: On postoperative day 1, the drain amylase levels of 350 patients were tested. Seventeen patients had postoperative leaks (4.8%); 14 of the 17 had leaks at the gastrojejunal anastomosis (82%). The median peak value for patients without leak was 79.5 IU/L+/-1,436.2 SD; for patients with leak it was 6,307 IU/L+/-50,166 (p < 0.0001, Wilcoxon rank sum test). All patients but one with a leak had a drain amylase > 400 IU/L. A drain amylase value of 400 IU/L empirically defines gastrojejunostomy leaks with a sensitivity of 94.1% and a specificity of 90.0%. Negative predictive value of a drain amylase level < 400 IU/L in excluding leak was 99.6%. Positive predictive value of a drain amylase > 400 IU/L in predicting leak was 33.3%. Of the 17 leaks, 7 required reoperation at a median of 1 day (mean, 1.6+/-1.1 days). There was no perioperative mortality. CONCLUSIONS: Drain amylase levels are a simple, low-cost adjunct with high sensitivity and specificity that can help to identify patients who may have a leak after gastric bypass surgery.