Roux-en-Y Gastric Bypass Hand-assisted Laparoscopy and Investigation of the Excluded Stomach

Abstract: Roux-en-Y gastric bypass (RYGBP) sustains weight loss and ameliorates diseases common in the morbid obese (BMI>40 kg/m2), but leaves the stomach and duodenum inaccessible. Morbidly obese patients have increased operative risks and in other fields minimal surgery is known to facilitate the postoperative course.The aim of this thesis was to evaluate hand-assisted laparoscopy in RYGBP and develop techniques to study the excluded stomach.The hand-assisted technique was developed in 13 patients and subsequently compared to open surgery in a blinded, prospective, randomised trial of 50 patients.Hand-assistance was feasible with a low need for conversions or re-operations. The duration of surgery was longer (150 versus 85 minutes) and postoperative results were similar to those in open surgery. Thus, the patients did not appear to derive benefits from hand-assisted laparoscopy. Interventional radiology accessed the excluded stomach and allowed endoscopy, barium studies and acid measurements. Chronic gastritis and low acid production were found. After RYGBP, 8 of 22 patients (36%) had duodenogastric bile reflux (DGBR), when studied by HIDA-scintigraphy. No DGBR was seen among controls. The gastric mucosa was evaluated by serology(pepsinogen I (PGI), H. pylori and H,K-ATPase) in 64 patients before and 1-4 years after operation. RYGBP, in contrast to gastric restriction, had reduced PGI levels postoperatively. According to serology, the mucosa is atrophic or in a resting state.This study focuses on safety in RYGBP. Hand-assisted laparoscopy was feasible, but not favourable compared to an optimised open procedure. The excluded stomach is no longer inaccessible and characterised by chronic gastritis, low acid production and frequent bile reflux.