2007 CROSSFIRE: OPEN VS. LAPAROSCOPIC ROUX-EN-Y

JONES: Laparoscopic vs. Open Roux-en-Y Gastric Bypass: Does the Data Support One Method Over the Other?

Kenneth B. Jones, Jr., MD, FACS, is Clinical Assistant Professor of Surgery, Louisiana State University, Health Sciences Center, Shreveport, Louisiana.

The term “minimally invasive, open Roux-en-Y gastric bypass with a left subcostal incision (RYGBP-LSI)” appears to be an oxymoron. “Open RYGBP” means a xiphoid to umbilical midline incision, but that may not always be the case. Many bariatric surgeons use a much smaller incision, and in over 4,000 bariatric cases (including various gastroplasties earlier on and then RYGBP in the past 20 years), I have used a left subcostal incision exclusively, which levels the laparoscopic versus open playing field, relative to abdominal access.

To develop my position that the open technique is at least as beneficial if not more so than laparoscopic, I need to discuss a paper I presented at the 22nd annual meeting of the ASBS in Orlando in 2005 and that was published in Obesity Surgery in June, 2006. It was entitled, “Open Roux-en-Y Gastric Bypass versus Laparoscopic: A Comparative Study of over 25,000 Open Cases and the Major Laparoscopic Bariatric Reported Series.”[1] It is assumed, and today well accepted, that laparoscopic gastric bypass (LRYGBP) is the preferred technique, or at least that is the public perception, because there is less pain, lower risk, a shorter length of stay, is less expensive because the patient returns to work sooner, and subsequently is more attractive to the individual patient.

Where is the data to support this? In order to answer that question, we need to discuss leaks, wounds, and other morbidities, cost effectiveness and ease of the comparative operations, time to return to work, average length of stay postoperatively, and mortality rates comparing the two procedures.

Suffice it to say that multiple laparoscopic versus open RYGBP studies indicate no significant difference in short-term weight loss.[2]Eight of our 16 surgeon contributors in the study mentioned previously had a mean excess weight loss of 63 percent at five years postoperative. My personal experience at 10 years is 62 percent weight lost and maintained.[1]

In our study, we looked at and found the following: Staple line failure, or gastro-gastric fistulae: 0.9%; incisional hernias: 6.6%; re-operations within 30 days postoperative: 0.7%; leaks: 0.34%; average length of stay: 3.4 days; return to work: 21 days; and mortality rates of 0.25%. In my personal contribution to this series of 2,746 cases, there was no significant difference compared to the mean of these parameters and the entire study. These data compare quite favorably to the laparoscopic data to follow.

If we look at leaks involving Schauer,[3] DeMaria and Sugerman,[4] Wittgrove and Clark,[5] Champion,[6] and Higa,[7] some of the best known and most widely published laparoscopic bariatric surgeons in the literature, you will note that their laparoscopic leak rate was 1.75 percent, compared to our open leak rate of 0.34 percent, which gave us a highly clinically significant advantage using the open approach (Table 1). Three other retrospective comparative studies in the literature of laparoscopic versus open RYGBP revealed almost the same thing, that is, laparoscopic leak rates close to two percent, compared to open leak rates of about 1.6 percent—no clinically significant difference.[9-11] However, as is pointed out by Paxton and Matthews,11 the average open patient had a BMI three points greater than the laparoscopic group, or was approximately 20 pounds heavier. Podnos noted that in the laparoscopic series, only 13 percent of the patients were males, compared to 18 percent in the open series, again indicating that the more difficult, heavier males were placed in the open group.[9] These three retrospective comparative studies in which there is obvious bias in patient selection are at best Level III studies, and therefore a very poor standard for comparison.

Paxton and Matthews stated in their paper that, because it is so technically demanding, laparoscopic RYGBP was more frequently done by surgical attendings and fellows, while open procedures were performed or were assisted by residents, which undoubtedly plays a role in the difference in complication rates in open versus laparoscopic series, indicating a learning curve of 50 to 200 laparoscopic gastric bypass patients, which is corroborated by many other papers in the literature.11

Combining Podnos[8] and Higa’s[12] postoperative laparoscopic RYGBP small bowel obstruction (SBO) data, we find an incidence of 157 in 4,887 (3.2%). Comparing this data to that of Jones and Capella,1 7 of 1,913 (0.4%), there is a very significant difference favoring the open approach (p=<0.001). Podnos8 also points out a significantly higher rate of gastro-jejunostomy stomal stricture and GI hemorrhage requiring intervention with LRYGBP.

In the pre-laparoscopic era, incisional hernias were downplayed since patients rarely suffered incarceration, and it also gave them an opportunity to have a panniculectomy done at the same time the hernia was repaired, at a much lower cost to the patient. Great emphasis is now placed on the paucity of incisional hernia and wound morbidity using the laparoscopic approach as its main justification.

Next, we considered cost. I, along with two other surgeons in our series, looked specifically at this issue, and found that there was an approximate $3,000 difference in instrument cost. If one adds the extra time that it takes to do laparoscopic gastric bypass compared to open, and subtract about $1,000 per day in the hospital, as the laparoscopic patients usually go home a day earlier, there is approximately a $7,000 to $8,000 additional charge to the patients or third party carriers. In fact, in our bariatric surgery Center of Excellence in Shreveport, we have found that to date, operating room (OR) cost, including time, supplies, and instrumentation, is approximately $9,000 for open gastric bypass compared to $18,000 for laparoscopic.
In 2004, there were approximately 140,000 bariatric cases that were done in the US, about half being the LRYGBP (ASBS estimate). If we were to add $8,000 per case times 70,000, this would be an additional $560 million. If we add in the extra cost of leaks, which occur at least 1.5 percent more often with laparoscopic cases, and assuming we are now doing 200,000 cases a year, this now works out to be about a billion dollars in excess cost to the third party carriers or cash-paying patients—just to do this same operation laparoscopically. No wonder the insurance carriers are reacting with a dictum for a 6- to 12-month period of worthless dieting, which translates into denials, then appeals, then more denials and more delays, the ploy being to pass this patient on to the next health insurer (which ultimately the patient will have, as the average US employer changes group health insurance policies about every 2.5 years). Of course, another reaction is a moratorium on bariatric surgery completely, similar to that which occurred in 2005 in Florida with Blue Cross.

Considering all of the above, comparing the two approaches, we now see that the laparoscopic approach results in significantly more leaks, more GI hemorrhage (requiring re-operation or attention thereto), more small bowel obstruction immediately and down the road, and more stomal stenosis, whereas there are considerably more wound problems using the open approach via a midline incision. As I alluded to earlier in this discussion, I have been using a left subcostal incision 20 to 25cm in length during my entire bariatric surgery career for gastric procedures, which now spans over 25 years and 4,000+ cases. Comparing my data and that of Alvarez-Cordaro, utilizing this incision, and the midline incision of Drs. Mason,[13] Amaral,[14] Sugerman,[15] and Alvarez-Cordaro[16] using a vertical incision, the rate of discernible vertical incisional hernias was 38 times greater.[17] I have done spot checks through the years and found that our incisional hernia rate in primary gastroplasty or Roux-Y gastric bypass procedures to be less than one percent. Comparing this data to that of Schauer,[3] Sugerman,[4] and Wittgrove and Clark,[5] I found no significant difference in incisional hernias comparing the LSI to the multiple small incisions of LRYGBP.[17]

Concerning mortality rates, our Orlando group,1 the laparoscopic group of Podnos,[8] and the International Bariatric Surgery Registry (IBSR) open 2002 pooled data and open RYGBP were virtually the same at 0.25 percent, 0.23 percent, and 0.27 percent, respectively. Podnos’ data indicates a significantly higher mortality rate in the open series, for which I have the following explanation: 1) There were more men, and patients were on average 20 pounds heavier in the open groups in those retrospective comparative series; 2) our Orlando group demonstrated that when the more difficult, heavier males and other more complicated cases are done open, their higher morbidity and mortality is absorbed and diluted by the much higher concentration (85%) of females; and 3) again, according to Paxton and Matthews,[11] open RYGBP procedures are more frequently done by residents, and laparoscopic procedures are done by fellows and staff with more experience and a higher skill level.

It is not unusual today for bariatric programs to be closed down because the tendency is to do more laparoscopic cases, which are more expensive to the hospital due to higher risks and expensive complications, and the lack of real cost effectiveness.

So if we have a procedure that has a higher learning curve, a higher risk of leaks, bleeding, postoperative stomal stenosis, and small bowel obstruction, and a higher cost in a patient population that is discharged on an average of 2.5 days, when most leaks are not noticed until three-plus days, and the average return to work difference between laparoscopic and open is less than one week, why do we continue to pursue a policy that continues to put us further behind the eight ball?
Our 2005 ASBS Orlando paper concluded that the data discussed here indicated no real advantage of laparoscopic over open RYGBP, and really reflected quite the opposite—particularly if one takes the incision and wound morbidity out of the equation. We are now left with a safer, less expensive, equally effective procedure in open.[1] Following the presentation, critique from the audience revealed a lot more positive than negative responses (Table 2). As a matter of fact, 98 percent of the responses indicated that they felt I was personally free of any bias in the presentation, and other remarks, such as “Benchmark paper,” “Great talk,” “Most important paper of the conference,” “Excellent presentation,” and “Excellent accountability of laparoscopic surgeons” were given. Of course, there were others like “Old disgruntled surgeons—need to get a life,” “Biased and wrong” (hard to understand that one after the data that I presented), “Irresponsible paper,” “Opinion” (however, it is based on facts and a thorough examination of the data), and “Stop trying to justify your existence.” Last but not least, “The worst.”
All the above being said, the bariatric surgical community continues to favor laparoscopic RYGBP because we have experienced the “perfect storm,” as the patient sees an easier, less painful operation with barely visible scars and less down time, and somehow they have been convinced that it is safer. Our new generation of surgeons has been raised during the video game and computer era, with excellent eye-hand coordination and an attitude that open is obsolete, and although they readily admit that the laparoscopic approach is more difficult to do, it is certainly more interesting to do, and they feel that “If I don’t do it, I’ll have no practice.” The third ingredient in this triangle is industry, which certainly supports the high tech philosophy, convincing surgeons that it is really not that difficult to do; it is the wave of the future; there is less pain for the patient, with less scarring; and the suggestion, “If you don’t jump on the bandwagon, you will be left behind.” Of course, there is lots of money to be made, as I have demonstrated, with an increase of technical sales by industry of over one half billion dollars per year for LRYGBP alone, excluding laparoscopic band profits.

I am not so naïve not to realize that the horse is indeed out of the barn and galloping around unbridled. The only way to tame this animal is proper training, which will require mini-fellowships of several months duration in programs with seasoned, laparoscopic bariatric surgeons who are doing LRYGBP. The Lap band is a separate issue, with different, less stringent criteria, and can be done with far less training by an experienced laparoscopic surgeon. The ball is in our court, and the ASBS has developed the Surgical Review Corporation (SRC) in an effort to assure better quality in all phases of our bariatric surgery. We only hope that this has been done in time to prevent us from continuing to shoot ourselves in the foot, which could ultimately be the death knell for bariatric surgery and its coverage by third party carriers.

References

1. Jones KB, Afram JD, Benotti PN, et al. Open versus laparoscopic Roux-en-Y gastric bypass: A comparative study of over 25,000 open cases and the major laparoscopic bariatric reported series. Obes Surg 2006;16:721–27.
2. Lujan JA, Frutos MD, Hernandez Q, et al. Laparoscopic versus open gastric bypass in the treatment of morbid obesity: A randomized perspective study. Ann Surg 2005;239:438–40.
3. Schauer PR, Ikramuddin S, Gourash W, et al. Outcomes after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Ann Surg 2000;232:515–29.
4. DeMaria EJ, Sugerman HJ, Kellum JM, et al. Results of 281 consecutive total laparoscopic Roux-en-Y gastric bypasses to treat morbid obesity. Ann Surg 2002;235:640–7.
5. Wittgrove AC, Clark GW. Laparoscopic gastric bypass, Roux-en-Y—500 patients: Technique and results, with 3–60 month follow-up. Obes Surg 2000;10:233–9.
6. Champion JK, Hunt T, DeLisle N. Role of routine intraoperative endoscopy in laparoscopic bariatric surgery. Surg Endosc 2002;16(12):1663–5.
7. Higa KD, Bone K. Ho T. Complications of the laparoscopic Roux-en-Y gastric bypass: 1,040 patients—What have we learned? Obes Surg 2000;10:509–13.
8. Jones KB. Bariatric surgery—Where to we go from here? Int Surg 2004;89:51–7.
9. Podnos YD, Jimenez JC, Wilson SE et al. Complications after laparoscopic gastric bypass—A review of 3,464 cases. Arch Surg 2003;138:957–61.
10. Baker RS, Foote J, Kemmeter, et al. The Science of stapling and leaks. Obes Surg 2004;14:1290–8.
11. Paxton JH, Matthews JB. The cost effectiveness of laparoscopic versus open gastric bypass surgery. Obes Surg 2005;15:24–34.
12. Higa KD, Ho T, Boone KB. Internal hernias after laparoscopic Roux-en-Y gastric bypass: Incidence, treatment, and prevention. Obes Surg 2003;13:350–54.
13. Mason EE. Surgical treatment of obesity. London: WB Saunders;1981: 340–1.
14. Amaral JF, Thompson WR. Abdominal closure in the morbidly obese. Proceedings of the Third Annual Meeting of the American Society for Bariatric Surgery, 1986, Iowa City, Iowa;191–202.
15. Sugerman, HJ, McNeill PM. Continuous absorbable vs. interrupted non-absorbable suture for midline fascial closure. Proceedings of the Second Annual Meeting of the American Society for Bariatric Surgery, 1985, Iowa City, Iowa;153–4.
16. Alvarez-Cordero R, Aragon-Viruette E. Incisions for obesity surgery: A brief report. Obes Surg 1991;1:409–11.
17. Jones KB Jr. The left subcostal incision revisited. Obes Surg 1998; 8: 225–8.
18. Hutter M, et al. Laparoscopic versus open gastric bypass for morbid obesity: A multicenter, prospective, risk-adjusted analysis from the National Surgical Quality Improvement Program. Ann Surg 2006;657–66.
19. Capella, RF, et al. Bowel obstruction after open and laparoscopic gastric bypass surgery. J Am Coll Surg 2006;203:328–35.

HIGA: “It is not white hair that engenders wisdom.”
Menander (342 BC–292 BC)

Dr. Higa is Assistant Clinical Professor in Surgery, University of California at San Francisco-FRESNO, Director, Bariatric and Minimally Invasive Surgery, Fresno Heart and Surgical Hospital, Fresno, California.

The publication in Obesity Surgery by Ken Jones and colleagues entitled, “Open versus Laparoscopic Roux-en-Y Gastric Bypass: A Comparative Study of Over 25,000 Open Cases and the Major Laparoscopic Bariatric Reported Series” reminds us of a similar discussion regarding the introduction of laparoscopic cholecystectomy of the last century. In 1991, over 600,000 patients in the US had their gallbladders removed. This significant increase in patients was not due to an increase in prevalence of the disease; it was due to increased patient awareness and acceptance for less invasive surgery. This significant increase in patients was not due to an increase in prevalence of the disease; it was due to increased patient awareness and acceptance for less invasive surgery. With the advent of minimally invasive techniques, the threat of this new, “unproven” technology brought on skepticism and criticism by the established general surgeons.

In response to global concerns regarding costs and complications, the National Institutes of Health (NIH) issued a consensus statement in September, 1992, after reviewing the available literature, stating: “Laparoscopic cholecystectomy provides a safe and effective treatment for most patients with symptomatic gallstones. Indeed, it appears to have become the treatment of choice for many of these patients.”[1]

My concerns at that time paralleled those of Dr. Jones today: “…many new laparoscopic surgeons, seeing new surgical opportunities, have entered the field with their learning curves.” Knowing that the sum total of all the laparoscopic incisions was equal to my subcostal incision, that most of my patients were discharged in less than 24 hours, and my “skin to skin” incision time was less than 40 minutes made a compelling argument not to embrace this procedure. However, the simple prospect of causing patients less pain was intriguing enough to endure the learning curve myself. Fortunately, I was not alone, and the laparoscopic approach to gallstones has become the undisputed standard of care. This experience is crossing over to many other operations, such as for GERD, splenectomy, adrenalectomy, and colon pathologies.

Concurrently, I also developed an interest in bariatric surgery and began performing the open Roux-en-Y gastric bypass through increasingly smaller midline incisions, as opposed to the left-subcostal incision preferred by Dr. Jones, but not adopted by other “seasoned” open bariatric surgeons. My four-inch incision made for a longer operation, and did not change my hernia rate of six percent or lessen the inpatient stay of 2 to 3 days. However, patients and cosmetic surgeons were very appreciative of the extra effort. Yes, even bariatric surgeons must consider the aesthetic consequences of their actions, whether it is to create a large scar or excessive, redundant skin. Every surgeon should also respect the environment they leave behind for the next surgeon, whether that involves intra-abdominal adhesions, altered gastrointestinal (GI) anatomy, or scars that cannot be revised.
So, it is not without some understanding and empathy for Dr. Jones’ concerns regarding cost, complications, and the integrity of this new breed of laparoscopic bariatric surgeons “seeing new surgical opportunities” for income enhancement that I reviewed Dr. Jones’ paper and rationale for promoting open bariatric surgery. However, we need to examine Dr. Jones’ arguments based on data rather than perception and individual prejudice.

“The great enemy of the truth is very often not the lie—deliberate, contrived, and dishonest, but the myth, persistent, persuasive, and unrealistic. Belief in myths allows the comfort of opinion without the discomfort of thought.”
John F. Kennedy (1917–1963)

Dr. Jones pooled data from 16 “seasoned, open bariatric surgeons” amassing a total of 25,759 individual cases. This data was self-reported and not validated by the constraints of publication in a peer-reviewed journal, such as was the case for the laparoscopic comparison. After looking at Dr. Jones’ pooled data, the following questions are immediately apparent: How were these “seasoned” surgeons chosen? Why were respected surgeons such as Sugerman,[2] Pories,[3] Brolin,[4] and Fobi[5] left out? Why did Dr. Jones choose not to survey “seasoned” laparoscopic surgeons in the same way as the open surgeons? Clearly, there is a major problem with this method.

Regardless of the open cohort, all laparoscopic reports include the learning curves of developing, not just learning, a new operation. The comparison of “seasoned” surgeons’ experience to the initial laparoscopic experience is simply not valid and is designed to make a point rather than study the issue.
Dr. Jones attempts to compare early complication rates as defined by fistulas, leak, return to surgery, mortality, and incisional hernias. Unfortunately, comparatively speaking, his data is so much better than the published reports that it undermines the validity and power of this study. Additionally, Dr. Jones makes no attempt to gather data from 16 “seasoned” laparoscopic surgeons and erroneously assumes the reported outcomes of the laparoscopic series are representative of the current state of affairs.

In a meta-analysis, Podnos, et al.,[6] clearly showed that laparoscopic gastric bypass had lower wound complications, hernias, and deaths compared with open gastric bypass. In a multi-institutional, prospective, risk-adjusted cohort study, Hutter, et al., reported laparoscopic gastric bypass had fewer complications than open gastric bypass using National Surgical Quality Improvement Program (NSQIP) data.[7]

Dr. Jones’ cost analysis is seriously flawed by the method in which he calculated the cost differential, again by survey rather than actual payments. In contrast, Paxton, et al.,[8] compiled data from the Agency for Healthcare Research and Quality (AHRQ), Health Economic Resource Center (HERC), and year-adjusted US Bureau of Labor and Statistics and Consumer Price Index in order to obtain a true cost differential. The total cost of the laparoscopic procedure was only $667 more than that of the open, but in the final cost analysis incorporating the increased complication rate of the open procedure and the loss of wages, the laparoscopic gastric bypass had an advantage of over $2,783 per procedure. That translates to a savings of over $400 million per year.

Having bariatric surgery does not protect patients from developing other diseases, such as malignancy. The American Cancer Society estimates a risk of 1 in 17 for 2006. The resultant internal adhesion rate and scar formation add to the complexity of both diagnosing and treating intra-abdominal malignancies in both open and laparoscopic surgery, but certainly much less so for the minimally invasive approach.
Small bowel obstruction after laparoscopic gastric bypass never achieved a rate higher than five percent, and has been almost entirely eliminated by either closing the potential internal hernia defects more effectively or adopting the antecolic approach. This phenomenon has, of course, been described in the open gastric bypass as well, but to a lesser degree due to the greater degree of intra-abdominal adhesion formation.

Finally, there are only three randomized, controlled studies comparing laparoscopic versus open gastric bypass, all of which found the laparoscopic approach superior to the open approach.[9–11]

We can universally agree that the revolution of minimally invasive bariatric surgery has improved patient and society awareness of the problems of obesity and the benefits of bariatric surgery. The tremendous growth in numbers of surgeons performing bariatric surgery and corresponding members of the American Society for Bariatric Surgery (ASBS) underscores the need for additional training and education of surgeons and not artificially rationing care by subjecting patients to unnecessary painful, disfiguring incisions and higher complication rates associated with open surgery.

Disclosure

Dr. Ken Jones is a personal friend and colleague whom I admire and respect greatly.

References

1. Gallstones and Laparoscopic Cholecystectomy. National Institutes of Health Consensus Development Conference Statement. September 14–16, 1992.
2. Sugerman HJ. Treatment of obesity. J Gastrointest Surg 2003;7(4):476–7.
3. Pories W, et al. Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus. Ann Surg 1995;222(3):339–50.
4. Brolin R, et al. Long-limb gastric bypass in the superobese. A prospective randomized study. Ann Surg 1992;215(4):387–95.
5. Fobi MAL, et al. Gastric bypass operation for obesity. World J Surg 1998;22(9):925–35.
6. Podnos Y, et al. Complications after laparoscopic gastric bypass: A review of 3,464 cases. Arch Surg 2003;957–61.
7. Hutter M, et al. Laparoscopic versus open gastric bypass for morbid obesity: A multicenter, prospective, risk-adjusted analysis from the National Surgical Quality Improvement Program. Ann Surg 2006;657–66.
8. Paxton JH, Matthews JB. The cost effectiveness of laparoscopic versus open gastric bypass surgery. Obes Surg 2005;15:24–34.
9. Nguyen NT, Goldman C, Rosenquist J, et al. Laparoscopic versus open gastric bypass: A randomized study of outcomes, quality of life, and costs. Ann Surg 2001;234:279–91.
10. Westling A, Gustavson S. Laparoscopic vs. open Roux-en-Y gastric bypass: A prospective, randomized trial. Obes Surg 2001;11:284–92.
11. Lujan JA, Frutis MD, Hernandez Q, et al. Laparoscopic versus open gastric bypass in the treatment of morbid obesity: A randomized prospective study. Ann Surg 2004;239:433–7.

Dr. Jones’ Rebuttal to Dr. Higa’s Crossfire…

With all due respect to my good friend, colleague, and President-Elect of the ASBS, I must say that many of his remarks in response to my thesis are not totally accurate and are misleading.

Laparoscopic cholecystectomy was a great boon to mankind, and I embraced it just as he did in the early 1990s, but we would all agree that LRYGBP is a much more difficult procedure and, therefore, claims of dual efficacy cannot really be made as these two procedures cannot be compared relative to degree of difficulty.

Yes, we are a group of “seasoned,” white-haired, old guys, but how else would 16 of us have done over 25,000 cases, except over a period of many years? Our “myths” are indeed backed by data, as perception that LRYGBP is better and “safer,” primarily an issue of incisional hernias, is a moot argument with the LSI. This misperception is fueled by the three large, comparative studies,9-11 as well as Hutter’s[18] paper to which Dr. Higa refers, all of which have high risk patients in the open group, with 50 percent more males with significantly higher BMIs and heavier weights. The basis of this bias is obvious: Do the easier (open) operation on the more technically challenging, higher risk patients and expect more complications.

To continue to equate safety and higher complication rates primarily with incisional hernias, ignoring the significantly higher incidence of SBOs, postoperative bleeding, and the greater need to return to emergency surgery for leaks is a whitewash of “more complications in the open group,” when the wound issue is potentially neutralized with the LSI.

This is a study of “open” surgeons who would do the vast majority of their cases in this fashion. Sugerman, Brolin, Fobi, and Pories are now predominantly laparoscopic bariatric surgeons. Regardless of who the comparisons included, I can only used published data, and if the laparoscopic series were now considerably better with lessons learned during this 13-year “learning curve,” then we may very well have comparable data, as Higa states that I “erroneously assume the reported outcomes of the laparoscopic series are representative of the current state of affairs.”

Costs are very difficult to compare, as there are so many factors involved in each locale: Decreased cost of equipment with increased volume; sweetheart contracts; charges to the patient as well as the health insurer and actual reimbursement for same; and the difficulty in obtaining accurate facts and figures for all the above. Capella19 has shown incidents of postoperative LRYGBP SBO would be in the vicinity of 10 percent, considerably higher than a rate Dr. Higa cites as never higher than five percent.

The three randomized controlled studies comparing LRYGBP to ORYGBP comprised two very small groups, confirming a higher risk of “complications” primarily related to wound problems, which can be virtually eliminated via the LSI. One of these studies was so early in the group’s experience that 23 percent were converted to open. Twenty-six percent of the LRYGBP group had to go back to surgery for SBO at the mesocolic opening. LRYGBP took an average of three hours and 55 minutes compared to one hour and 40 minutes for ORYGBP in this small series of 50 patients. How can we make critical decisions about surgical technique based on a series with so few patients?

Bottom line: Open RYGBP–LSI is truly a minimally invasive (traumatic) procedure that should always be in the bariatric surgeon’s armamentarium for the more technically difficult, larger male and revisional patients, if not for all.

Tables 1 and 2

Further Debate…

Higa: In the data you presented in your “Orlando 16” paper, you mentioned staple line failure (SLF) or gastro-gastric (G-G) fistula. Is SLF a leak?

Jones: Some of us separate our proximal and distal gastric pouches with an intact staple line and some transect the pouches exactly as it is done with LRYGBP. SLF, or G-G fistula, refers to something that happens much later on, not associated with an acute postoperative leak in the first few days. SLF and G-G fistula are therefore synonymous with an opening between upper and lower pouches, but not an acute postoperative leaking staple line, requiring emergent return to surgery.

Higa: The data that you submitted in your “Orlando 16” paper is unsubstantiated and unverified. I therefore feel it lacks credibility. Please respond.

Jones: Our data has certainly been verified. It was published in the peer-reviewed journal Obesity Surgery in June, 2006.

Higa: It has been well established that the learning curve for LRYGBP is considerably longer than open. How long do you think this mini-fellowship for LRYGBP needs to be?

Jones: Dr. Higa, I think that you need to answer that question. Several years ago, the ASBS had an open as well as laparoscopic preceptorship for RYGBP, and 2 or 3 industrial suppliers had weekend courses to “train” open bariatric surgeons to learn the laparoscopic approach. Of course, they had no intention of considering these surgeons then well trained, able to return to their home environment and safely do these procedures immediately, but many did so anyway as they then began their “learning curve.”

These weekend “quickie” courses were abandoned about three years ago quite suddenly, about the same time there was a moratorium placed on preceptorships, both open and laparoscopic. I was an open preceptor, and have been in touch with several of my preceptees who have gone back home and done RYGBP-LSI with good outcomes, so I believe if a surgeon spent two weeks with me or any other seasoned open RYGBP bariatric surgeon, they could develop sufficient expertise with this procedure in a very short period of time. We all know that the same cannot be said of LRYGBP.

Therefore, I think the ASBS has thrown the baby out with the bathwater by totally abandoning the preceptorship program, and in particular open preceptorships.

Category: Interviews, Past Articles