title: Early experience with two-stage laparoscopic Roux-en-Y gastric bypass as an alternative in the super-super obese patient.
abstract: BACKGROUND
  Surgical management of the supersuper obese patient (BMI >60 kg/m2) has been a challenging problem associated with higher morbidity, mortality, and long-term weight loss failure. Current limited experience exists with a two-stage biliopancreatic diversion and duodenal switch in the supersuper obese patient, and we now present our early experience with a two-stage gastric bypass for these patients.
  
  
  METHODS
  We completed a retrospective bariatric database and chart review of super-super obese patients who underwent laparoscopic sleeve gastrectomy as a first-stage procedure followed by laparoscopic Roux-en-Y gastric bypass as a second-stage for more definitive treatment of obesity.
  
  
  RESULTS
  During a two-year period, 7 patients with BMI 58-71 kg/m2 underwent a two-stage laparoscopic Roux-en-Y gastric bypass by two surgeons at the Mount Sinai Medical Center. 3 patients were female, 4 patients were male, and the average age was 43. Prior to the sleeve gastrectomy, the mean weight was 181 kg with a BMI of 63. Average time between procedures was 11 months. Prior to the second-stage procedure, the mean weight was 145 kg with a BMI of 50 and average excess weight loss of 37 kg (33% EWL). Six patients have had follow-up after the second-stage procedure with an average of 2.5 months. At follow-up the mean weight was 126 kg with a BMI of 44 and average excess weight loss of 51 kg (46% EWL). The mean operative times for the two procedures were 124 and 158 minutes respectively. The average length of stay for all procedures was 2.7 days. 4 patients had 5 complications, which included splenic injury, proximal anastomotic stricture, left arm nerve praxia, trocar site hernia, and urinary tract infection. There were no mortalities in the series.
  
  
  CONCLUSIONS
  Laparoscopic sleeve gastrectomy with second-stage Roux-en-Y gastric bypass are feasible and effective procedures based on short-term results. This two-stage approach is a reasonable alternative for surgical treatment of the high-risk supersuper obese patient.
authors.affiliation: Division of Laparoscopic Surgery, Department of Surgery, Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1103, New York, NY, USA.
authors.forename: J P
authors.initials: JP
authors.lastname: Regan
authors.forename: W B
authors.initials: WB
authors.lastname: Inabnet
authors.forename: M
authors.initials: M
authors.lastname: Gagner
authors.forename: A
authors.initials: A
authors.lastname: Pomp
mesh_terms: D000328:Adult; D000713:Anastomosis, Roux-en-Y; D005240:Feasibility Studies; D005260:Female; D005743:Gastrectomy / Q000379:methods*; D015390:Gastric Bypass / Q000379:methods*; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D009767:Obesity, Morbid / Q000601:surgery*; D012189:Retrospective Studies; D012720:Severity of Illness Index; D016896:Treatment Outcome