title: Staged laparoscopic Roux-en-Y: a novel two-stage bariatric operation as an alternative in the super-obese with massively enlarged liver.
abstract: In a subset of super-obese patients, the one-stage laparoscopic Roux-en-Y gastric bypass (RYGBP) can be associated with significant morbidity and mortality. In a previous effort to reduce the perioperative risks associated with the super-obese, a two-stage operation was devised. This two-stage operation consisted of a sleeve gastrectomy (1st stage) followed by a RYGBP or duodenal switch procedure (2nd stage). We find that the primary limiting factor making laparoscopic gastric bypass challenging in the super-obese is the volume of the left lobe of the liver. A greatly thickened left lobe of the liver obscures visualization of the gastroesophageal junction and angle of His so that a sleeve gastrectomy is difficult to construct. In this report, we describe a novel method utilizing a staged Roux-en-Y procedure. Instead of performing a restrictive operation (sleeve gastrectomy) as the initial procedure, we fashion a modified Roux-en-Y with a low gastrojejunal anastomosis and a larger gastric pouch encompassing the gastric fundus. The low anastomosis obviates the need for exposure of the gastro-esophageal junction and angle of His. At the 2nd stage procedure, completion sleeve gastrectomy of the gastric fundus is performed at an interval of 6-12 months after the 1st stage operation.
authors.affiliation: Department of Surgery, University of California, Irvine School of Medicine, Irvine, CA 92868, USA. ninhn@uci.edu
authors.forename: Ninh T
authors.initials: NT
authors.lastname: Nguyen
authors.forename: Mario
authors.initials: M
authors.lastname: Longoria
authors.forename: Dmitri V
authors.initials: DV
authors.lastname: Gelfand
authors.forename: Allen
authors.initials: A
authors.lastname: Sabio
authors.forename: Samuel E
authors.initials: SE
authors.lastname: Wilson
mesh_terms: D000713:Anastomosis, Roux-en-Y; D049088:Bariatrics / Q000379:methods; D015390:Gastric Bypass / Q000379:methods*; D006529:Hepatomegaly / Q000150:complications*; D006801:Humans; D010535:Laparoscopy; D009767:Obesity, Morbid / Q000150:complications / Q000601:surgery*