Long-term complications of laparoscopic Roux-en-y gastric bypass: Strategies for prevention, diagnosis, and management

Long-term complications of laparoscopic Roux-en-y gastric bypass: Strategies for prevention,  diagnosis,  and management

Ahmed H Abdelhajez, MD; Gamal Fawzy, MD; Mohamed Aamer, MD; MRCs

Department of General Surgery, Ain Shams University, Cairo, Egypt

Abstract

Background:Laparoscopic RYGB simultaneously causes food malabsorption  and restricts food intake and generally results in more weight loss than restrictive operations, including the Lap-Band gastroplasty. Patients who have laparoscopic RYGB generally lose about two-thirds of their excess weight in 2 years and within 3 years they lose 68-72% of excess weight. At ten years, most patients continue to keep off at least 50% of the excess weight.Long-term complications include pouch stretching,  and gastrojejunal anastomotic strictures. Because  gastric bypass operations  cause food to skip the duodenum, risks for nutritional deficiencies  are higher than for restrictive procedures. Anemia may result from malabsorption  of vitamin B12 and iron in menstruating women, and decreased absorption of calcium may bring on osteoporosis and bone disease. Long-term  complications may also include deficiencies  in vitamins A, D, E, Bl, B6, and folic acid. Patients must take nutritional  supplements daily to manage these side effects.

Patients and methods: The study consisted of 40 patients operated upon from January 2005 to September 2009 with minimal follow up of 6 months. Patients, who are operated before May

2008, were 20 patients and they were studied retrospectively. Prospective study was conducted on 20 patients who were operated on from May 2008.

Results:  Nineteen patients  (57.5%)  developed late complications (>30 days). One patient

developed  myocardial ischemia  (2.5%)which was treated  by stent and resolved,  3 patients developed prolonged nausea (7.5%) which resolved spontaneously, 2 patients (5%) developed repeated  vomiting  which  resolved  spontaneously, 2 patients   developed  gastrojejunostomy anastomotic stricture  (5%) which resolved  after endoscopic balloon dilatation, one patient (2.5%) developed symptomatic gall stones and was treated by laparoscopic cholecystectomy, one patient developed  marginal ulcer(2.5%)  and was treated by proton pump inhibitors  and resolved. One patient  developed  depression and he was normal preoperatively, however he received medications and improved. One patient developed incisional hernia (2.5%) at trocar site which was repaired. Six patients (15%) developed iron deficiency anemia and were treated by iron. One patient (2.5%) developed protein-calorie malnutrition and improved with TPN and dietary counseling.

Conclusions: The important outcome related to the goal ofbariatric surgery such as weight loss, important reduction in comorbidities and good quality of life results in this study appear acceptable if compared with other series.

Key words: Obesity, laparoscopic, gastric bypass.

Introduction:

In the gastric bypass procedure a surgeon directly connects the upper portion of the stomach to a lower segment of the small intestine, bypassing part of the stomach, the duodenum and part of the jejunum. By creating a path for food that goes around part of the stomach and the small bowel, the operation

causes food to be poorly digested and absorbed (food malabsorption). The Roux-en-Y gastric bypass (RYGB) is currently the most common bypass procedure. It combines elements of both  stomach-restricting and bypass operations) Laparoscopic RYGB has  the advantages of earlier mobilization with less pain  in  the  postoperative period,  shorter

postoperative hospital stay and sick leave, and a lower risk of incisional hernia than the open procedure.2 Morbidity (complications) in the early post-operative Period from wound infection, leaks from staple-line breakdowns, marginal ulcers, various pulmonary problems and deep  venous  thrombosis (DVT) may  be as  high  as  20%.3  Gall  stone formation is common following rapid weight loss either by dietary methods or by bariatric surgery.4 Any patient with non   specific post operative symptoms of crampy abdominal pain  often warrants investigation. Severe chest pain out of  proportion to  physical examination is worrisome for cardiac ischaemia Often patients with internal  hernias will not vomit, but they mayretch.5

Until  recently, bariatric surgery protocol included annual screening of calcium, phosphorus, magnesium, and  albumin after GB. With  newer literature, suggesting that patients who undergo GB are at increased risk for  vitamin D  deficiency, screening was updated to include both 25-hydroxyvitamin D (vitamin D) and parathyroid hormone (PTH) levels.6 Roux-en-Y gastric bypass (RYGB) results in a loss of approximately 65% of excess body weight in severely obese patients. However, up  to 30%  of GB patients regain weight after surgery and consistent presurgery predictors of long-term outcome have not been established.7

The purpose of this study was to evaluate long-term complications oflaparoscopic Roux­ en-Y  gastric bypass and  show  strategies for prevention, diagnosis, and  management.

Patients and methods:

This study was conducted in El Demerdash and Ain Shams Specialized Hospitals in Egypt and AL-Nahda Hospital in KSA; on 40 patients operated on from January 2005 to September

2009  with  minimal follow up of 6 months. Patients were selected for laparoscopic Roux­ en-Y  gastric bypass (LRYGB) if  they  met minimal criteria for bariatric surgery proposed by National Institute ofHealth (Nlli) consensus Development panel  report  1991; body  mass index  more than 40 or more than 35 with co­ exiting  morbidity (diabetes, dyslipedemia or/ and hypertension) and the patients had history

of obesity for more  than 5 years with  failure of conservative treatment more than 2 years. According to  American Society of Anesthesiologist (ASA) classification, patients of ASA III, IV or V were excluded from  the study.

Preoperative assessment:

All patients  were preoperatively evaluated including history and physical examination, nutritional and  psychiatric evaluation and specialty consultations if indicated. Laboratory evaluation included complete blood count, organ chemistry profiles, thyroid function testing, and blood  sugar  tolerance curve and glycated hemoglobin (AlC)  level. ECG, echocardiography and abdominal  sonography were done for all patients. If gall stones were detected then laparoscopic cholecystectomy was  performed concomitantly. Pulmonary function tests were done  to every  patient. If dyspepsia was present; upper  GI endoscopy was performed. Patients preparation for surgery consisted of a detailed explanation in written and oral form of the developmental aspect of laparoscopic RYGB and its benefits and risks, including short- and long-term complications, side  effects, nutritional sequelae, and  the possibility of conversion to the open procedure. Informed consent was obtained. Preoperative bowel cleansing and perioperative antibiotics were administered. Prophylaxis against venous thrombosis and pulmonary embolus consisted of  perioperative pneumatic compression devices and low-molecular subcutaneous anti­ thrombotic (Clexane).Data were collected and entered into a customized computer data base. Data sources included office charts, follow-up notes,  hospital charts,  and patient  interview. Parameters included patient demographics, comorbidity, surgical time,  blood  loss,  pain medication requirement, hospital stay, recovery, complications, weight loss, and  change in comorbidity, quality oflife changes, and patient satisfaction. Outcomes related to changes in comorbidities, quality of  life, and  patient satisfaction were  assessed for  patients at 6 months  or more of follow-up. Late morbidity

and mortality were considered after thirty days

from the operation.

Surgical technique:

After induction of  general anesthesia, creation  of   pneumo-peritoneum   and introduction of  ports, exploration of  the abdomen was done. The greater omentum and transverse colon were passed to the  upper abdomen  to expose the ligament ofTreitz. To create the   Roux limb, the   jejunum was transected with an Endo GIA II stapler  (U.S. Surgical), 45-mm length and 3.5-mm staples, at approximately 30 em from the ligament of Treitz, where a comfortable length of mesentery exists. A smaller staple size (2.5 mm) was later substituted to reduce  staple line bleeds  at the transected bowel.  The jejunal mesentery was then divided with two applications  of the Endo GIA II stapler using the vascular load (45-mm length, 2.0-mm staples). Vicryl stitch was sewn to the end of the Roux limb. The Roux  limb was  then  measured 150  em  distally for the superobese, and   a  stapled side-to-side anastomosis was created with  the proximal jejunal limb using one application of the Endo

GIA stapler n(60-mm length, 3.5-mm staples).

Later, a 2.5-mm staple cartridge was used.The enterotomy sites were stapled closed  and the mesentery of jejunojejunostomy was sutured closed. A window was created in the  lesser omentum near  the  gastric wall  at the  lesser curvature. The   Endo GIA stapler  (U.S. Surgical), 60-mm  length and 4.8-mm  staples, was inserted and  applied  three  or four  times to staple and cut the gastric pouch  with three rows of staples on each side. A smaller staple size (3.5 mm) was later substituted to reduce staple  line bleeds at the transected stomach. The gastrojejunostomy was then created using a linear technique.  The  gastrojejunostomy anastomosis was  closed with interrupted

3--0 Polysorb suture (U.S. Surgical). The gastric pouch and Roux limb were irrigated with dilute methylene blue dye to detect leaks. A 10 French drain was placed posterior to the gastrojejunal anastomosis and brought out through a right subcostal port site.

Postoperative assessment:

Patients began  ambulating on the evening of  surgery. Pain  management consisted of narcotics intravenously as needed. A Clear liquid diet was begun  in the 2nd day  and the

patient was discharged from the hospital after demonstrating tolerance to diet and return  of bowel fimction, usually on the 3rd postoperative day. Gastrographin study was done in the 3rd post-operative day.The drain was removed on the  Jrd postoperative day  and  the  diet  was advanced to solid food by the 4th postoperative week. Monitoring of  early postoperative morbidity  and  mortality  was  done.

Patient follow-up:

Follow up was scheduled every  2 weeks, with  laboratory evaluation every 2 months, and gastrographin study was done if dysphagia occurred. Follow up until weight loss stabilized (usually  within one year), then twice per year.

Statistical analysis:

Analysis of data was doneby ffiM computer

using  SPSS  (Statistical Program for  Social Science version  12) as follows: description of quantitative variables  as mean, SD and range, and  description of  qualitative variables as number and percentage, and paired t-test was used to compare quantitative variables in the same group before and after  intervention. P­ value (level of significance) was non significant (NS) ifP>0.05, significant ifP<0.05 and highly significant (HS) ifP<O.Ol.

Results:

Twenty four females (60%) and 16 males (40%) were operated on. Mean age of females was 31 years (range from 23 to 48 years) and the mean  age for males  was 32 years  (range from 21 to 47 years).  The mean preoperative body mass index (BMI) was 42.4 (k:g!m2) with range  from  36 to 49 (kg!m2) and ASA  class was 25 patients ASA.I (62.5%) and 15 patients ASAII  (37.5%). A total of224 comorbidities were  identified in the  40  patients (5.6  per patient) of which 45 (20%) were newly diagnosed during the preoperative assessment. The  most  common comorbidities included, degenerative joint disease in 22 patients (55%), hypercholesterolemia in 21 patients (52.5%), hypertension in 18 patients  (45%), gastroesophageal reflux  disease in 18 patient (45%), depression in  16  patients (40%), hypertriglyceredemia in  16 patients (40%), sleep  apnea 15  (37.5), fatty  liver  disease in

14(35%), urinary stress incontinence in 12 patients (30%), type II diabetes in 10(25%), cholelethiasis in 6 (15%) and asthma in 4 (10%) Table(l).

The changes inobesity related combidities postoperatively whether aggravated, unchanged, improved, or  resolved; are summarized in Figure(l).

The mean excess weight loss after 6 months  was  42.8%, after  12months was

58.8%, after 18 months was 65.8% after 24 months 73.2%, after 30 months was 71.8% and after 36 months the mean was 69.8% Figures(2)&(3).

Regarding postoperative recovery, patients began oral liquids in a mean of 1.58±0.2 days (range 1-3 days); the mean hospital stay was

3.6±0.8 days (range 1-17 days); the mean time of return to normal activities was 25.6:±:5 days (range 14-35 days);  the mean time of return to work was 29.2±10 days (range 14-

40 days) Table(2).

Nineteen patients (47.5%) developed late complications (>30  days) one patient developed myocardial ischemia (2.5%) which was treated by stent and resolved, 3 patients

Table (1): Overview and demographics.

developed prolonged nausea  (7.5%) and resolved spontaneously, 2 patients (5%) developed  repeated vomiting  and resolved spontaneously, 2  patients  developed gastrojejunostomy anastmotic stricture (5%) and  resolved after  endoscopic balloon dilatation, one patient developed symptomatic gall  bladder stones and  was  treated  by laparoscopic cholecystectomy, one patient developed  marginal  ulcer (2.5%) and was treated by  proton pump  inhibitors  and resolved, one patient developed  depression and he was normal preoperatively, however he received medications and improved, one patient developed  incisional hernia (2.5%) at trocar  site and was repaired,  6 patients developed iron deficiency anemia and was treated by iron, one patient (2.5%) developed protein-calorie malnutrition and improved with TPN and dietary counseling Table(3).

The mean change in body Fat Mass (FM)

measured preoperatively by Bioelectrical

Impedance Analysis (BIA) was 47.7% (range

42  to 52.8) and  the  mean change in preoperative Fat Free Mass (FFM) was 62% (range 47 to 68.2) Figure(4).

Table (2): Postoperative recovery.

Table (3): Distribution of the studied cases as regard lflle compUcations.

Joint dlseue

)P••I>Qiostonolem1e

H'll'•• tiJislon GERD Depre$sion

H)'l'etlngi)Vere<lemll

Slup apnea

Folly h.,.,

1'11'• 2diabolos

Aslllma

0             20            40            60      80            100

Figure (1): Change in obesity- related comorbidity.

MEAN % EXCESS WEIGHT LOSS WITH STANDRD DEVIATION

%80.00

%70.00

% 71.80

6                 5                  4                 3                  2

6 MONTH INTERVAL

Figure (2): Excess weight loss, 0 to 30 months.

IMEAN BMI WITH STANDRD DEVIATION  I

'll!! .,        .A 42.4

%60.00

%50.00

%40.00

%30.00

%20.00

%10.00

%0.00

45

40

27.93

;3{)-;A

....--

\               35

28.1     -                      .....          3'2

-\-   30

Lf.lb

20

\

15

10

5

.\    0

8             7             6              5             4       3              2              1

6MONTH INTERVAL

Figure(3):Changeinbody massindex,0to 30 months.

% 58.20

-.-FF-M .eF===-=.--          0160

% 58.70                                       {1(

0

% 28.90

-11-FM

_ %.2S 5.o                                    %_3_2_.8_o

%70

%60

%40

%30

-l

%20

%10

%0

4                        3                       2                           1

Discussion:

12 MONTH INTERVAL

Figure(4): Mean changein Fat Mass (FM) and Free Fat Mass

(FFM). 0 to 36 months.

techniques coupled with advanced suturing

RYGB is the surgical procedure of choice for morbid obesity because of its good long­ term weight loss, excellent patient tolerance, and  acceptable short- and  long-term complication rate. Laparoscopic bariatric surgery,  particularly laparoscopic GB, is technically challenging, as it requires skill in intestinal dissection and  reconstruction

and intra-corporeal knot-tying  techniques.

Therefore, the  development of  any  new laparoscopic operations can be associated with a "Learning curve".1 Mastering the technique oflaparoscopic GB often requires between 75 and 100 cases.Results oflaparoscopic surgery are more fairly compared to open bariatric surgery after  the  learning curve  of  the

laparoscopic operation has been achieved.8

As with most complex laparoscopic procedures, the learning curve is steep, and long operation times are required. Wittgrove et al, 2000 have found that with experience, operating times can be reduced  to close  to those for open RYGB.2

A laparoscopic approach to RYGB may offer benefits that have been shown to occur with other introduced laparoscopic procedure including a reduction in post operative pain and complications, a shorter hospital stay, and faster recovery. High-risk morbidly obese patients with multiple comorbidities may in particular benefit from a less invasive approach because they  are  more  vulnerable to cardiopulmonary and wound- related complications.2

A laparoscopic approach to RYGB was first described by Wittgrove et. al in 1994. 15- to

30-mL gastric pouch isolated from the distal stomach  with  a 21-mm  stapled, circular anastomosis, a 75-cm retrocolic, retro gastric Roux  limb,   and  a  stapled side-to-side jejunojejunostomy. They have reported on their experience with 75 patients with 3 to 30 months of follow- up. The operating time was 159 to

343 minutes. The mean hospital  stay and

recovery time were 2.8 days (range 2-75) and

15 days (range 7-30), respectively. Excess weight loss at 12 to 30 months was 81% to

95%. The incidence of major complication was 11%, and the leak rate was 4175 (5%). There were no deaths. Most comorbidities, such as hypertension and non-insulin­ dependent diabetes  mellitus, were  either eradicated or significantly improved. They have recently reported on their experience with

500  patients with   5-  year  follow   -up,

demonstrating similar result and excess weight loss in the 70% to 80%  range.2,9

Other investigators have reported various laparoscopic approaches to gastric bypass with similar benefit but relatively short follow-up.lO In  this  study, 40  patients underwent laparoscopic RYGB with an acceptable early complication rate (7.5% major, 30% minor), a low conversion  rate (5%)  a short  mean hospital stay (3.6 days) and rapid recovery (25.6 days). The excess weight loss at 24 and

36 months was 73.2% and 69.8%, respectively,

and resulted in significant  improvement  in comorbidities and quality of life.

Surgical complications in this  study appeared to be comparable to those in the open series. The early major complications were predominately related to sepsis from anastomotic leaks and pulmonary embolism. The overall incidence of these complications appears consistent with reports in the literature; however, slight higher incidence can be noticed due to small number of patients.In this study we were interested in the late complications and the long term outcome.

One of the most important late complications is the development of anastomotic (gastro­ jejunal) stricture, in this study it occurred in 2 patients (5%) and the recorded incidence in other studies is 1-15% of patients who undergo LRYGB and typically occurs within 2 years of the procedure. However, most of strictures seem to occur within 4-8 weeks after surgery.ll Inthis study one stricture occurred 6 months postoperatively and the second occurred after

14 months of surgery.

It is controversial  whether anastomotic technique, i.e., circular versus linear versus hand sewn, retrocolic versus antecolic, truly alters the incidence of stenosis. Some studies have suggested that circular stapled anastomosis may result in higher stricture rates than hand

sewn or linear stapled.lo

In a small, nonrandomized retrospective review  Gonzalez et al. (2003), found  a significantly higher stricture rate with the 21- mm circular stapled anastomosis than the hand sewn and linear stapled anastomosis (31% vs.

3% vs. 0%, respectively; P<0.01). However, the 31% with the circular seems quite high and although not stated, the linear technique was the first one used in our operative experience. There may be a trend toward a higher stricture rate with antecolic Roux limbs compared with retrocolic presumably secondary to tension on blood supply. Additionally, stapler diameter may influence the incidence of stenosis.II Nguyen et al. (2003) compared the stenosis rates with both the 21-mm and 25-mm stapler (26.8%  vs 8.8%,  respectively, P<0.01).12

Patients who develop anastomotic stenosis develop progressive vomiting first for solids and eventually liquids. The history of such

complaints  is vital  to recognition of  this complication. Constant and progressive vomiting is characteristic of stenosis, while episodic or transient vomiting is more likely from dietary indiscretion. Although generally not life threatening, unrecognized and prolonged vomiting resulting from anastomotic stenosis can cause dehydration. Also chronic protein-calorie malnutrition, and vitamin or thiamine deficiency may occur.13

Anastomotic strictures can  usually be diagnosed by  history alone; UGI fluoroscopy can also be  helpful in demonstrating narrowing of the gastrojejunal anastomosis and  delayed emptying of the gastric  pouch. However, should the suspicion of a stricture be high enough, upper endoscopy is superior because it not  only can  establish the diagnosis but treat it as well. Inability to pass a  9-mm endoscope through the anastomotic outlet is considered by many to be diagnostic of anastomotic stricture.13

Balloon dilatation with a through the scope balloon is highly effective in reestablishing an adequate lumen and resolving the patient's symptoms. A stepwise approach is usually performed, dilating 3-5 mm above the size of the lumen at the first endoscopy and then using subsequent endoscopy to dilate to a final lumen of12 mm.14

Inthis study the 2 strictures which occurred, successfully responded to endoscopic dilatation and resolved completely.

Patients with marginal ulcers will usually present with upper epigastric pain and burning sensation. The pain may radiate to the back. Substernal chest pain can also occur. Nausea, vomiting,  and  food  intolerance are  often commonly seen with ulcers; while massive upper GI (UGI) bleeding is uncommon, iron deficiency anemia is more  commonly associated with chronic or recurrent ulcers.I

Some studies have also suggested that the injudicious  use   of   nonsteroidal anti­ inflammatory agents, Helicobacter pylori, tobacco smoking, ischemia, and Roux limb tension are also possible etiologic factors. IS In divided RYGBs without gastro-gastric fistula, the etiology of marginal  ulceration remains unclear. Acid output by parietal cells in the standard 30-cc gastric pouch is minimal

but not usually absent. Large pouches may likely contain more acid- producing parietal cells thus  increasing the  incidence of ulceration.l6

The evaluation of a patient who presents with symptoms suggestive ofulceration is very straightforward. A barium swallow radiograph is simple, noninvasive, and often the first diagnostic test ordered. However, while it may delineate large deep ulcers and demonstrate gastro-gastric fistulas,  it might miss more shallow ulcerations. Upper endoscopy, while more invasive, is a superior test to diagnose ulceration. It is much  more  specific for identifying  ulcers. If an ulcer is found, the treatment includes removal of irritants such as tobacco or nonsteroidal anti-inflammatory drugs (NSAIDs) and the prescription of either a histamine-receptor antagonist or proton-pump inhibitor. Unless the ulcer is due to ischemia or a gastro-gastric fistula, medical therapy will

usually succeed.16

In the literature; marginal ulceration has been reported to occur in 5-15% and 3-5% of patients who undergo undivided and divided RYGB respectively.n

One case of marginal ulceration was recorded in this study (2.5%) and developed

4 month after surgery and responded well to

PPis.

One case of incisional hernia was reported postoperatively (2.5%) that was comparable with other studies ofLRYGB and much less with studies of open technique.

Iron is one of the most frequent deficiencies after obesity surgery; the incidence is about

14-16% in RYGB.l7

Six patients  (15%) developed anemia (mainly due to iron deficiency and other factors as folate and B12 deficiencies). The cases responded to parenteral iron and multivitamins.

Most multivitamin and mineral supplements contain  sufficient amount  of iron to prevent  deficiency. However, iron deficiency anemia  sometimes persist even in  patients taking multivitamins. As  a preventive measure, all menstruating women are prescribed ferrous  sulfate 325 mg  every  day.  Patients diagnosed with anemia are treated with ferrous sulfate 325 mg three times a day along with vitamin C.

Sometimes parenteral iron  therapy is necessary to correct anemia. Iron therapy is associated with constipation as a common side effect.18

Refractory and severe anemia  may require blood transfusion. Thiamine and folate deficiencies are suspected in patients who present after repeated vomiting. They should be treated with parenteral thiamine and folate before starting fluid replacement. Acute thianrine deficiency is treated with parenteral thiamine  1OOmg/d for 7 days followed by 10 mg/d orally until there is

complete recovery. Vitamin B12 deficiency has to be corrected by supplementing 300-

500 g/d orally or as 1000-2000 g/month

intramuscular shots. Protein deficiencies are  identified and  corrected by dietary modification and protein supplementation. Total parenteral nutrition may be necessary for patients with  extreme degree of malnutrition.19

In this study regular  examination and laboratory work up were done for patients every 2 months, measuring; CBC, vitamin B12  level, albumin, and  calcium. Replacement therapy was  given  if any deficiency was recorded in addition  to vitamin and mineral supplementation to all patients.

In a low acid environment as seen in achlorhydria and gastric bypass, absorption of calcium carbonate is poor. A recent study reported that  absorption of amino  acid chelated calcium is twice that of calcium carbonate.20

Recommended screening tests include Serum Ca, 25-0H  D,  and  PTH. Recommendations to prevent osteoporosis after GB include ingestion of 1200-1500 mg of calcium and 800 IU of vitamin D per day. If the patient has  extreme malabsorption, higher doses are needed to prevent secondary hyperparathyroidism. The efficacy of calcium absorption varies inversely with the calcium intake. At low doses (<500 mg), calcium absorption is by active transport.20

The important  outcome  related  to the goal of bariatric  surgery  such as weight

loss, important reduction in comorbidities and good quality of life results in that this study appears acceptable if compared with other  series putting  in consideration the limited  number of patients. In this study the mean  percent  of excess  weight  loss after 1, 2 & 3 years was 58.8%, 73.2 and

69.8%  respectively, similar  results were recorded by Yale.21

Robert et al. (2007), studied 320 patients who underwent laparoscopic RYGB with gastric  pouches  smaller than 60cc. They

lost about 55% of their excess weight after

6 months and after 12 months  the mean

loss was 69%, however, he concluded that; the theory why gastric bypass leads to weight loss depends on the pouch size to launch weight loss while maintenance depends more on endocrine changes such as decrease in Ghrelin hormone. He also added  that; significant weight  loss in patients undergoing LRYGB is mainly as a consequence of loss in Fat Mass (FM) with less  importance on Free Fat  Mass (FM).22  Similar results can be obtained from our study.

Nearly all comorbidities improved  or resolved after LRYGB with exception to neuropsychiatric comorbidities as depression even some cases deteriorated, however they improved  by medications. Similar results can be seen in the study of Saltzman et al., 2005 .23

Improvement  in quality of life in 95%

of patients studied in this study was impressive; however weight  gain  was noticed after 18-24 months in some patients. Signore concluded that, patients having gastric bypass were divided into groups regarding weight regain:

Group 1: about 25% of patients lose 80% of their excess weight, regardless of medical or support group's aid.

Group  2: 25% of patients  do not  lose

enough weight, or display weight regains, even with  medical and   support  group   care.

Group 3: about 50% of patients  might achieve good results, but this is primarily dependent on efficacy of medical staff and the attention of support groups. For these patients,

the ability of the multi-professional team  to keep patients involved in  support group programs is  vital. Should these data be confirmed, it is possible that,  in long-term analysis (5-10 years after surgery), almost half of the patients could  experience suboptimal results and he concluded that ifthe professionals involved in the obesity treatment don't  work together to solve  the weight  regain problem and control the eating compulsion, surgical

treatment will be compromised.24

The  Laparoscopic RYGB is  technically challenging but  with  experience it can  be mastered and the learning curve  is steep  and long operating times are required. At the start of this  study  the operating time  was around nine hours and less in some cases. Wittgrove et al. have found that with experience operating time can be reduced to close to those for open RYGB.9

Conclusion:

The  results of  this study indicate that laparoscopic RYGB is technically feasible and safe. It is associated with  a low  rate  of postoperative complications, a short hospital stay, and rapid recovery. Laparoscopic RYGB is a  promising bariatric procedure with potentially significant advantages over  the open approach, but  further evaluation is necessary to determine long term weight  loss and  complications. Also,  additional studies with  larger numbers of patients and  longer follow-up will  be  required to  answer the question unequivocally.

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