Page 24 - WALS Journal

WJOLS

Review of Various Aspects of Laparoscopic Roux-en-Y Gastric Bypass to Emphasize its Significance in Bariatric Surgery

HISTORY experienced a greater incidence of late complications
(p < 0.05), reoperations (p < 0.04), less weight loss
In 1954, Kremen et al performed the first intestinal bypass
via jejunoileostomy, and in 1956, Payne and DeWind (p < 0.001) and decreased overall satisfaction (p < 0.006).
performed a distal jejunocolonic anastomosis. Later it was Likewise, patients who underwent LRYGB had a greater
modified by Sherman et al, who sutured 14 inches of resolution of concomitant diabetes mellitus (p < 0.05) and
proximal jejunum end-to-side to the terminal ileum, 4 inches sleep apnea (p < 0.01) compared with the LAGB group.
proximal to the ileocecal valve. Mason and Ito devised a Furthermore, postoperative adjustments to achieve
gastric bypass procedure for morbid obesity in 1966, after consistent weight loss for LAGB recipients ranged from
noting the weight reduction in gastric resection for gastric 1 to 15 manipulations. Single mortality was also in this
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ulcer. Initially, they transected the stomach horizontally and LAGB group. In one another study, LAGB is found
performed a loop gastrojejunostomy to the proximal portion significantly associated with more late complications,
of the stomach. Over several decades, the gastric bypass reoperations, less weight loss, less reduction of medical
has been modified into its current form, using a Roux-en-Y comorbidity and patient dissatisfaction compared with
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limb of intestine (RYGBP). In 1994, Wittgrove, Clark and LRYGB.
Tremblay reported the first case series of laparoscopic The following table shows the outcome of different types
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RYGBP. 10 of bariatric operations (Table 1).
RYGBP IS SAFE AS WELL AS
SURGICAL TECHNIQUE
EFFECTIVE PROCEDURE
In LRYGBP procedure, six small incisions are made, The LRYGB has been shown to be safe and effective for
through which ports are inserted for abdominal access. the non superobese patient (BMI < 50) by Wittgrove et al. 16
Dissection is started at the fundus of stomach with division Using same techniques, Nguyen et al were able to perform
of phrenico-gastric ligament. The stomach is divided with RYGBP on a patient with a BMI of 61. Higa et al (2000)
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laparoscopic straight four row cutting 60 mm stapler to studied a case series of 400 morbidly obese and superobese
create a 15 to 20 cc pouch. The ligament of Treitz is individuals who underwent the LRYGB over a 22-month
identified initially, and the proximal jejunum is divided period. They observed that RYGBP can be safely and
approximately 50 cm distal to this point. A gastrojejunos- effectively performed in the community setting using
tomy is performed either hand sutured, linear staplers or by advanced laparoscopic techniques. 18
circular staplers. A jejunojejunostomy is performed
with laparoscopic staplers. A Roux limb of between 75 and LRYGP IS A REDO PROCEDURE FOR FAILED
200 cm is formed depending on the BMI, and the RESTRICTIVE GASTRIC SURGERY
jejunojejunal mesenteric defect is closed to avoid From the conclusion based on the various text, it can be
postoperative internal hernias. The Roux limb is placed in assumed that restrictive surgery for morbidly obesity will
an antecolic fashion. The anastomosis is tested by certainly require many reoperations in the future. The
gastroscopy for evidence of any leak after the procedure. standard operation of choice is LRYGBP. The study
conducted by Van Dessel et al (2006), has shown this
COMPARISON OF LRYGBP WITH OTHER procedure a higher, but not significantly early morbidity
METHODS OF LAPAROSCOPIC BARIATRIC rate when the indication for redo surgery was a technical
SURGERY
complication of the initial procedure. 19
LRYGP is in reality, a well-structured and well-understood
operation that is valuable for the treatment of clinical severe EFFECT OF RYGBP ON THE LEVEL OF
obesity. Longer follow-up evaluation and experience with SERUM GHRELIN
VBG shows that patients frequently changes dietary habits Ghrelin, an acylated protein, is an orexigenic hormone,
postoperatively, ingests high-calorie soft foods and liquids decreases after feeding and increases before meals,
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and regains weight. Because of these long-term results, achieving concentrations sufficient to stimulate hunger and
the operation has been largely abandoned. food intake. This hormone is basically produced from
A prospective, comparative analysis performed by entero-endocrine cells of gastric mucosa and somewhat from
Bowne et al (2006), has shown that the laparoscopic gastric the duodenum. RYGBP seems to achieve a very strong
bypass is superior to adjustable gastric band in super suppression of serum ghrelin level in contrast with gastric
morbidly obese patients. The patients who underwent banding procedure. These findings are consistent with the
laparoscopic adjustable gastric banding (LAGB) assumption that by suppression of ghrelin, gastric bypass
World Journal of Laparoscopic Surgery, September-December 2012;5(3):116-120 117