Open Roux-en-Y Gastric Bypass: A Footnote in the History of Bariatric Surgery or a Viable Entity?

by Kenneth B. Jones, Jr., MD, FACS

Clinical Assistant Professor of Surgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana.

INTRODUCTION

It has long been noted that transverse and oblique abdominal incisions are superior to vertical, as they result in fewer hernias and better abdominal access.[1,2] The extended right mid-abdominal transverse incision was made popular with the original jejunoileal bypass of the 1960s,[3] but Dr. Mason changed that when he introduced the gastric bypass in 1967,[4] as he felt that better access could be attained through an upper midline incision, and the whole world followed suit. Less morbid surgical access to the abdomen was the original argument in favor of laparoscopic (LRYGBP) over open (ORYGBP) Roux-en-Y gastric bypass surgery.[5] Once it gained instant popularity, we quickly realized there were many advantages to the laparoscopic technique, so much so that we ignored the negatives, and continue to do so.

We have quickly embraced LRYGBP for many reasons: The public loves it as it is “not a real operation” since there is no big incision, our younger generation of surgeons is enamored by the high-tech label, and industry has been the prime mover in this perfect storm for obvious reasons, exploiting the patient demand argument.

Once we got into it, it was clear that most patients were indeed up and around and out of the hospital sooner, did not seem to have as much pain, and postoperative return to normal bowel function occurred about one day earlier when compared to ORYGBP. Patients are interested in the aesthetic scar-free advantages and negligible wound morbidity of laparoscopic procedures. Surgeons are apt to take a patient back to the operating room more quickly to “drop in a scope” with the first hint of tachycardia than to reopen a large abdominal incision to look for a leak. This could be one reason for an apparent lower mortality rate despite more leaks with LRYGBP.

DISCUSSION

I and quite a few other surgeons, who some may call old-timers, are still avid supporters of the open technique for a number of reasons. LRYGBP is associated with more statistically significant bleeding, leaks, strictures, and small bowel obstructions,[6–12] and carries a higher cost[12] and a steeper learning curve. However, the surgical literature would lead us to believe otherwise, claiming that morbidity and mortality rates are higher in ORYGBP when comparing the two approaches. The megastudies of Podnos,[13] Baker,[14] Paxton,[15] Ricciardi,[16] and Hutter[17] continue to drive this “safer” theme home. However, these studies all note the negatives I mentioned here, and they are biased and strictly retrospective with significantly more males, higher BMIs, more patients with type II diabetes, and heavier average patient weights, all factors we know will significantly increase risk.[18] That is like handpicking all the 6’5” (or taller) guys in the gym for a pick-up basketball game. You’ll win 9 out of 10 times. Their hidden bottom line: LRYGBP is a harder operation. Therefore, do the technically tougher patients utilizing the easier open technique. “Safer” equals lower wound morbidity, which rarely, if ever, is a potential cause for increased mortality.

I would have long ago abandoned open for laparoscopic RYGBP if not for the left subcostal incision (LSI). The LSI is considerably stronger, resulting in less than a one-percent incisional hernia rate with fewer wound infections because it is never contaminated by the navel. The LSI is also less painful than a midline incision, since the intercostal anterior nerve branches are transected.[19] This levels the playing field, since it takes abdominal access out of the equation and leaves us with all the disadvantages of LRYGBP mentioned above. However, even I will have to admit that the horse is long since out of the barn, and the whole world is convinced that open is passé, as we are all getting to be much better technical laparoscopic surgeons. So, is ORYGBP now dead in the water and essentially a historical footnote? Based on all the above, we can still argue NO.

As all of us old guys fade into the sunset, we leave you younger surgeons with a few thoughts, which have taken us 50 years to learn but are essential if bariatric surgery is to continue as a major player in the treatment of the morbidly obese. First, the “steep” learning curve is not necessary. There are virtually none of us left who have not already sought training in laparoscopic techniques and are just now trying to learn new tricks in less than a week and putting them into practice. We now all know better (finally). Laparoscopic bariatric surgery is now a significant part of most general surgery training programs, as well as post-graduate minimally invasive surgical fellowships. Mini-fellowships of several months duration are available to teach practicing surgeons the newer techniques, and in my ASMBS presidential address in 2001, I emphasized this,[20] and either someone was listening or this idea’s time has evolved, or both. Shortly after that, there was a realization that the two-day weekend wonder courses were courting disaster, and they were abandoned. Drs. Schwarz and Drew are examples of individuals who were successful with the above, but they had a great deal of experience with the open RYGBP, and after taking a weekend course, returned home to their animal lab, honed their skills, did several open cases using laparoscopic instruments, and incorporated LRYGBP into their practice with no significant change in complications.[21] Of course, this is not possible today, as there are so few centers doing large numbers of open cases. But the mini-fellowships are available, with realistic mock-ups for one to utilize and become skillful with laparoscopic instruments, which will further decrease the learning curve.

Second, always keep in mind that the surgeon is in part a glorified technician; therefore, foremost in our minds should be such things as the following: Pouch size—too big or too small? Is there more tension on the antecolic gastrojejunostomy? Will that precipitate more leaks? Just because we are transecting the stomach, gastrogastric fistulae still occur, and there is a higher incidence of leaks from a transected staple line. Beware! Be careful about crossing staple lines at acute angles and avoid excessive dissecting and other maneuvers that could increase ischemia. Use of the electrocautery on staple lines may transmit the charge, causing invisible burns and delayed leaks. Carefully check the common channel for obstruction just distal to the entero-enterostomy. These are examples of a myriad of technical details that we need to constantly deal with, regardless of how we access the abdomen.

Third, even if we feel it is unethical, immoral, or perhaps even sub-standard to open a laparoscopic patient, we should always keep in mind that the open technique is usually easier to perform on men and on patients with higher BMIs, as well as in many revision procedures, particularly if we are using the LSI. Remember, the stomach is essentially in the left upper quadrant (LUQ) of the abdomen.[19] This incision can be adjusted slightly more caudad in order to incorporate the distal ileum to allow ease of performing biliopancreatic diversion (BPD) and BPD/duodenal switch (DS) and not sacrifice wound strength.

CONCLUSION

LRYGBP is the most popular bariatric surgical procedure performed in the US today, with the lap-band® running a close second. The rapidity with which we have developed the ease and dexterity to do these procedures is remarkable, and for that reason they are here to stay. In foreign countries, surgeons appear more apt to re-use disposable products due to their efficiency, ease of gas sterilization, and fewer medical-legal encumbrances. Operating room costs for LRYGBP, including use of trocars, endostapling devices, and Harmonic® scalpels, plus the added hour or so on the operating room table add several thousand dollars per case. In my principal hospital, it adds up to $9000 more, which trumps by far the $1500 savings for a one-day earlier discharge, and this is charged to the LRYGBP patient and/or third party payers. Therefore, it is incumbent upon us to make significant adjustments in cost control, as the third party carriers are really the final arbiters in this debate. We all want the easy way out. This frequently means LRYGBP for the patient and ORYGBP for the surgeon.

REFERENCES
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Category: Commentary, Past Articles