Background: Since 1994, laparoscopic Roux-en-Y gastric bypass (LRYGBP) has gained popularity for the treatment of morbid obesity. In analogy to open surgery, the operation was initially performed in a retrocolic fashion. Later, an antecolic procedure was introduced. According to short-term studies, the antecolic technique is favorable. In this study, we compared the retrocolic vs the antecolic technique with 3 years of follow-up. We hypothesized that the antecolic technique is superior to the retrocolic in terms of operation time and morbidity. Methods: 33 consecutive patients with retrocolic technique and 33 patients with antecolic technique of LRYGBP were compared, using a matched-pair analysis. Data were extracted from a prospectively collected database. The matching criteria were: BMI, age, gender and type of bypass (proximal or distal). The end-points of the study were: operation time, length of hospital stay, incidence of early and late complications, reoperation rates and weight loss in the followup over 36 months. Results: In the retrocolic group, operation time was 219 min compared to 188 min in the antecolic group (P = 0.036). In the retrocolic group, 3 patients (9.1%) developed an internal hernia and 4 patients (12.1%) suffered from anastomotic strictures. In the antecolic group, 2 patients (6.1%) developed internal hernias and in 3 patients (9.1%) anastomotic strictures occurred. Median hospital stay in the retrocolic group was 8 days compared to 7 days in the antecolic group. In the antecolic group, the mean BMI dropped from 46kg/m2 to 32kg/m2 postoperatively after 36 months. This corresponds to an excess BMI loss of 66%. In the retrocolic group, we found a similar decrease in BMI from preoperative 45kg/m2 to 34kg/m2 after 36 months (P = 0.276). Conclusion: The results of our study demonstrate a reduction of operation time and hospital stay in the antecolic group compared to the retrocolic group. No differences between the two groups were found regarding morbidity and weight loss. Taken together, the antecolic seems to be superior to the retrocolic techniqu

Clavien, Pierre-Alain

Guber, Ivo

Guber, Josef

Müller, Markus

Weber, Markus

Wildi, Stefan

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© Springer Science + Business Media, Inc. Obesity Surgery, 17, 2007   889Obesity Surgery, 17, 889-893Background: Since 1994, laparoscopic Roux-en-Ygastric bypass (LRYGBP) has gained popularity forthe treatment of morbid obesity. In analogy to opensurgery, the operation was initially performed in aretrocolic fashion. Later, an antecolic procedure wasintroduced. According to short-term studies, theantecolic technique is favorable. In this study, wecompared the retrocolic vs the antecolic techniquewith 3 years of follow-up. We hypothesized that theantecolic technique is superior to the retrocolic interms of operation time and morbidity.Methods: 33 consecutive patients with retrocolictechnique and 33 patients with antecolic technique ofLRYGBP were compared, using a matched-pair analy-sis. Data were extracted from a prospectively collect-ed database. The matching criteria were: BMI, age,gender and type of bypass (proximal or distal). Theend-points of the study were: operation time, lengthof hospital stay, incidence of early and late complica-tions, reoperation rates and weight loss in the follow-up over 36 months.Results: In the retrocolic group, operation time was219 min compared to 188 min in the antecolic group(P=0.036). In the retrocolic group, 3 patients (9.1%)developed an internal hernia and 4 patients (12.1%)suffered from anastomotic strictures. In the antecolicgroup, 2 patients (6.1%) developed internal herniasand in 3 patients (9.1%) anastomotic stricturesoccurred. Median hospital stay in the retrocolic groupwas 8 days compared to 7 days in the antecolicgroup. In the antecolic group, the mean BMI droppedfrom 46 kg/m2 to 32 kg/m2 postoperatively after 36months. This corresponds to an excess BMI loss of66%. In the retrocolic group, we found a similardecrease in BMI from preoperative 45 kg/m2 to 34kg/m2 after 36 months (P=0.276).Conclusion: The results of our study demonstrate areduction of operation time and hospital stay in theantecolic group compared to the retrocolic group. No dif-ferences between the two groups were found regardingmorbidity and weight loss. Taken together, the antecolicseems to be superior to the retrocolic technique.Key words: Morbid obesity, bariatric surgery, laparoscopicRoux-en-Y gastric bypass, technique, internal herniaIntroduction Roux-en-Y gastric bypass (RYGBP) is the mostcommon operation for morbid obesity in the UnitedStates.1,2 The different surgical techniques forRYGBP are still under intense discussion. Several randomized controlled trials have con-firmed the advantages of the laparoscopicapproach.3-5 Since its introduction in 1994, laparo-scopic RYGBP has rapidly gained popularity,6 andthe majority of surgeons have adopted this tech-nique.7 In a review of 18 studies comparing laparo-scopic with open RYGBP between 1994 and 2002,Podnos et al8 showed a significant decrease of iatro-genic splenectomy, wound infection, incisional her-nias, and mortality with the laparoscopic approach.However, there was an increased incidence of anas-tomotic strictures and of bowel obstruction as aresult of internal hernias.8,9One area of continued debate is the orientation ofthe Roux or alimentary limb, i.e. retrocolic (RC) ver-sus antecolic (AC). Analogous to the open surgery,the operation was initially performed in a retrocolicfashion. The antecolic technique was introducedlater, and was considered to be technically easier andThree-Year Follow-Up Study of Retrocolic versusAntecolic Laparoscopic Roux-en-Y Gastric BypassMarkus K. Müller, MD; Josef Guber, MD; Stefan Wildi, MD; Ivo Guber, MD;Pierre-Alain Clavien, MD, PhD; Markus Weber, MDDepartment of Visceral and Transplantation Surgery, University Hospital Zurich, SwitzerlandCorrespondence to: Markus Weber, MD, Department of Visceraland Transplantation Surgery, University Hospital Zürich,Rämistrasse 100, 8091 Zürich, Switzerland. Fax: +41 (0) 44 25544 49; e-mail: markus.weber@usz.chresulting in less complications.10,11 Which of thesetechnical modalities is superior from a long-termperspective is unknown, because comparative dataare lacking. Several cohort studies describe the dif-ferent approaches, but only short-term outcome hasbeen reported.8,12,13Our study compares the outcome of both technicalmodalities over a 3-year period. Both groups werecompared by a matched-pair study design, analyz-ing a large prospectively-collected database. Wehypothesized that the antecolic technique is superi-or to the retrocolic in terms of operative time andmorbidity, but we did not expect a difference inpostoperative weight loss.Patients and MethodsA total of 33 consecutive patients with a retrocoliclaparoscopic RYGBP were compared to 33 patientswith an antecolic approach, using a matched-pairmethod. The operations were performed betweenJuly 2000 and November 2002. Both proximal (ali-mentary limb of 150 cm) and distal (common chan-nel of 150 cm) bypass procedures were performed.At the beginning, only the retrocolic technique wasused. Later, the technique was switched to theantecolic procedure, as a consequence of the unsat-isfying results reported in the literature regardingthe retrocolic approach.14 The data were extractedfrom a prospectively-collected database of allpatients (n>500) undergoing bariatric surgery at theDepartment of Visceral and Transplantation Surgeryat the University Hospital Zurich. The patients werematched according to age, gender, body mass index(BMI) and type of bypass (proximal or distal). Theend-points of the study over a follow-up of 36months were operative time, length of hospital stay,postoperative BMI as well as excess BMI loss(EBL), and complication rates with special empha-sis on internal hernias. Surgical TechniqueAll bypass procedures were performed laparoscopi-cally as described by Wittgrove in 1994.6 Briefly, asmall gastric pouch of 15-25 ml is created. Next, thejejunum is transected 50 cm distal to the duodeno-jejunal flexure, and the jejuno-jejunostomy is per-formed using a linear stapler. The mesenteric win-dow at the jejuno-jejunostomy is closed with one ortwo single stitches using a non-absorbable suture(Ethibond™). Either an alimentary limb length of150 cm in the proximal bypass or a common chan-nel of 150 cm in the distal bypass is chosen, depend-ing on the preoperative BMI. The alimentary limb isthen brought up to the gastric pouch. The gastro-jejunal anastomosis is performed with a circular sta-pling device (CEEA 25-mm, Tyco, Mansfield, MA),which is inserted transabdominally. In the antecolictechnique, the alimentary limb is brought up direct-ly to the pouch, whereas in the retrocolic approach,the Roux limb is passed through a mesocolic win-dow. The mesocolic window and the Petersen’sdefect were not closed with sutures.Statistical AnalysisThe statistical analysis was performed using standardsoftware SPSS 12.0 for Windows (SPSS, Chicago,IL, USA). Our null hypothesis was that there was nodifference between the two groups; the null hypothe-sis was rejected at a level of α<0.05. The Mann-Whitney-U test was used to compare continuous vari-ables between the two groups. Categorical variableswere compared using the χ2 test, or when appropri-ate, Fischer’s exact test was applied. Results areexpressed as mean and standard deviation (SD),unless otherwise stated. A P-value <0.05 was consid-ered to indicate statistical significance.Results According to the matching criteria, the patients werecomparable regarding age, gender, BMI, and proxi-mal or distal gastric bypass. The two groups consist-ed of 25 female and 8 male patients each. The meanage in the retrocolic-treated patients was 41 years(range 26-59) and in the antecolic-operated groupwas 42 years (range 24-60). Preoperatively, the aver-age BMI in the retrocolic group was 45.0 kg/m2(range 34.6-64.6) and in the antecolic group was 45.7kg/m2 (range 35.6-65.9). The characteristics of thepatients are presented in Table 1.Muller et al890 Obesity Surgery, 17, 2007The average operation time in the retrocolic groupwas 219 minutes compared to 188 minutes in theantecolic group (P=0.036). Postoperative complica-tions occurred in 21% (n=7) of the patients in theretrocolic group and in 15% (n=5) in the antecolicgroup, respectively (P=0.751). Internal hernias (3 vs2) and anastomotic strictures (4 vs 3) were not sig-nificantly different between the two groups. In con-trast, the median length of hospital stay was shorterin the antecolic bypass group in comparison to theretrocolic bypass group (7 vs 8 days, P=0.013). Theresults are summarized in Table 2.Interestingly, almost all internal hernias occurredin the mesenteric window of the jejuno-jejunostomy(Table 3). They became symptomatic late in the fol-low-up, and after a significant weight loss of usually>10 BMI points. In contrast, the single transmescol-ic hernia already became symptomatic 2 weeks afterthe operation. The hernias were diagnosed laparo-scopically and were repositioned after conversion toopen surgery. In only one case, the reposition couldbe achieved by laparoscopy. The mesenteric windowwas always closed with sutures. In one case, thesmall bowel was partially incarcerated and had to beresected. The relation between BMI and time ofoccurrence of internal hernia is shown in Figure 1. The follow-up rate was 88% after 3 years, and themean length of follow-up was 34.5 months. Theweight loss in the two groups was comparable andis shown in Figure 2. DiscussionTwo technical modalities in LRYGBP are the retro-colic and antecolic positioning of the Roux limb.The technical challenge of a retrocolic Roux-limbpositioning is undisputed. The transposition throughthe mesocolic window in a more or less blind fash-ion, and the poorer tactile properties of the laparo-scopic instruments lead to a more challenging pro-cedure compared to open surgery. In contrast, theantecolic positioning allows visual control of theRoux-limb orientation and its integrity. In order tocompare these two different techniques, we chose amatched-pair analysis and established two homoge-neous patient groups according to the matching cri-teria. The analysis of our 3-year results now demon-strates that the more time-consuming and technical-ly-challenging retrocolic procedure has no advan-tage over the antecolic Roux-limb positioning interms of weight loss and late complications. Thehigher complexity of the retrocolic positioning ismirrored in the longer operative time in our study. A specific problem of LRYGBP operations is theoccurrence of internal hernias. This finding might beexplained in part by the more difficult exposure ofthe small bowel and the related mesentery, as well asthe more complex suturing of the laparoscopicapproach.8,9 Typical localizations of hernias afterRetrocolic vs Antecolic Laparoscopic Roux-en-Y Gastric BypassObesity Surgery, 17, 2007   891Table 1. Patient CharacteristicsAntecolic Retrocolic(n=33) (n=33)Age (y) (SD) 42.0 (9.8) 41.3 (9.7)range 24-60 26-59Gender (f/m) 25/ 8 25/ 8BMI (kg/m2) (SD) 45.7 (6.0) 45.0 (6.2)range 35.6-65.9 34.6-64.6Bypass typealimentary 150 cm(proximal) 24 24common channel150 cm (distal) 9 9Table 2. ResultsAntecolic Retrocolic POperation time(min) 188 (SD 48.8) 219 (SD 57.4) 0.036Conversion toopen (n) 1 2 1Length of stay(median, d)* 7 8 0.013range 4-24 4-43Overall complicationsn (%) 5 (15) 7 (21) 0.751Internal hernia (n) 2 3Anastomoticstricture (n) 3 4Death (n) 0 0*In the Swiss system, we do not have same-day admissions,and patients are discharged home (and not to an affiliatedinstitution), when oral intake is sufficient and patients can takecare of themselves alone including self-administration of lowmolecular weight heparin SC. This accounts for longer lengthof stay than in the USA.LRYGBP are the mesenteric window of the distaljejuno-jejunostomy and the window behind themesentery of the Roux-limb (Petersen’s hernia). Theretrocolic Roux-limb positioning has an additionalpossibility for a herniation of the small bowelthrough the mesocolic window. This is one reasonwhy the retrocolic RYGBP has a higher rate of inter-nal hernias in the literature.10 Although rare, internalherniation can cause massive bowel infarction andbowel perforation; therefore, timely recognition anda low threshold for operation is crucial.12-14In our study, we could not demonstrate a differ-ence in incidence of internal hernias in the twogroups, probably due to the small sample size. Acomparison of occurrence at the mesocolic windowwas not possible because the event was rare (n=1).Surprisingly, our rate of internal hernias was rela-tively high (7.5%) compared to other studies, whichreport  internal hernia rates between 1.5 % and3.1%.8,10,12,13 This might be due to the consistenthigh follow-up rate and the longer period of obser-vation in our study. In most other studies, internalhernias are described after 2110 or 150 days.13Additionally, in our institution, the patients afterLRYGBP are brought back to surgery with a lowthreshold for a diagnostic laparoscopy in the case ofunexplained abdominal pain, because internal her-nias are very difficult to detect. To date, no consis-tent clinical signs or diagnostic tests exist that canconfirm or rule out an internal hernia with adequatereliability. A contrast follow through can be falselynegative in a high rate.8 Abdominal CT scan withoral contrast has the potential to diagnose an inter-nal hernia, but this examination is not sensitiveenough to be routinely recommended.12When performing laparoscopy, we recommendstarting the exploration from the ileocecal valve,working the way along the small bowel proximally.The common channel, which is herniated in themajority of cases, is reduced gradually this way. Inour experience, it can be more difficult to reduce thehernia if one starts at the alimentary Roux limb.After the reduction of the hernia, the mesentericdefect can be closed laparoscopically. If the reduc-tion is not possible or if small bowel has to be resect-ed, conversion to open surgery is recommended.  Muller et al892 Obesity Surgery, 17, 2007Table 3. Types of internal hernias Patient Type Internal hernia Time (m) BMI loss Consequence1 RC distal anastomosis 26 14 conv & reposition2 RC transmesocolic <1 1 conv & reposition3 RC distal anastomosis 4 10 open reposition4 AC distal anastomosis 9 13 lap & reposition5 AC distal anastomosis 8 14 conv & resectionRC: retrocolic, AC: antecolic, conv: conversion from laparoscopy to open surgery, lap: laparoscopy.202530354045500 12 24 36Months follow-upBMIPatient 1 Patient 2 Patient 3Patient 4 Patient 5 Occurence of IHFigure 1. Relationship between the occurrence of an inter-nal hernia (IH) and the BMI and/or the time of occurrence.30.035.040.045.050.0kg/m2retrocolic 45.0 35.2 33.2 33.8 33.6antecolic 45.7 34.6 31.3 30.9 32.10 6 12 24 36Figure 2. The decrease of body mass index (BMI) points wascomparable in both procedures during follow-up (P=0.276).Months follow-upMonths fBMI (kg/m2 )BMI (kg/m2 )Retrocolic vs Antecolic Laparoscopic Roux-en-Y Gastric BypassObesity Surgery, 17, 2007   893One reason for the emergence of internal herniasis the incomplete closure of the mesenteric defect atthe first operation.9 In our technique, the mesenteryat the jejuno-jejunostomy was split only 2-3 cm androutinely closed with one or two non-absorbablesutures. Interestingly, the majority of internal her-nias in this study occurred after a significant weightloss. This fact suggests that weight loss leads to anincrease in existing small mesenteric defects due toslimming of the mesentery. In addition, we believethat a slender mesentery results in a higher mobilityof the small bowel, which might further enhance therisk of herniation.Internal hernias occurred as late as 2 years afterRYGBP indicating that the risk for this complica-tion might remain during the rest of life. The cumu-lative incidence of internal hernias might thereforebe much higher than reported in the literature orcommunicated to patients.Whether the higher tension on the antecolic Rouxlimb leads to a higher rate of strictures is discussedcontroversially.15 We could not find a difference,although the small sample size and the relatively rareevent do not allow statistical analysis. Other factorslike the use of reinforcement sutures and the size ofthe circular stapler are believed to be more importantfactors for the development of a stricture.15According to our results, we conclude that theantecolic Roux limb positioning is easier, faster andequally effective and safe in the long-term, com-pared to the retrocolic method. Therefore, theantecolic approach represents the better alternativein laparoscopic gastric bypass surgery.References1. Sauerland S, Angrisani L, Belachew M et al. Obesitysurgery: Evidence-based guidelines of the EuropeanAssociation for Endoscopic Surgery (EAES). SurgEndosc 2005; 19: 200-21.2. Buchwald H, Avidor Y, Braunwald E et al. Bariatricsurgery: a systematic review and meta-analysis.JAMA 2004; 292: 1724-37.3. Lujan JA, Frutos MD, Hernandez Q et al.Laparoscopic versus open gastric bypass in the treat-ment of morbid obesity: a randomized prospectivestudy. Ann Surg 2004; 239: 433-7.4. Nguyen NT, Goldman C, Rosenquist CJ et al.Laparoscopic versus open gastric bypass: a random-ized study of outcomes, quality of life, and costs. AnnSurg 2001; 234:279-89; discussion 289-91.5. Westling A, Gustavsson S. Laparoscopic vs openRoux-en-Y gastric bypass: a prospective, randomizedtrial. Obes Surg 2001; 11: 284-92.6. Wittgrove AC, Clark GW, Tremblay LJ. Laparoscopicgastric bypass, Roux-en-Y: Preliminary report of fivecases. Obes Surg 1994; 4: 353-7.7. Jones DB, Provost DA, DeMaria EJ et al. Optimalmanagement of the morbidly obese patient SAGESappropriateness conference statement. Surg Endosc2004; 18: 1029-37.8. Podnos YD, Jimenez JC, Wilson SE et al.Complications after laparoscopic gastric bypass: areview of 3464 cases. Arch Surg 2003; 138: 957-61.9. Higa KD, Ho T, Boone KB. Internal hernias afterlaparoscopic Roux-en-Y gastric bypass: incidence,treatment and prevention. Obes Surg 2003; 13: 350-4.10.Champion JK, Williams M. Small bowel obstructionand internal hernias after laparoscopic Roux-en-Ygastric bypass. Obes Surg 2003; 13: 596-600.11.Schauer PR, Ikramuddin S, Hamad G et al.Laparoscopic gastric bypass surgery: current tech-nique. J Laparoendosc Adv Surg Tech A 2003; 13:229-39.12.Cho M, Carrodeguas L, Pinto D et al. Diagnosis andmanagement of partial small bowel obstruction afterlaparoscopic antecolic antegastric Roux-en-Y gastricbypass for morbid obesity. J Am Coll Surg 2006; 202:262-8.13.Eckhauser A, Torquati A, Youssef Y et al. Internalhernia: postoperative complication of roux-en-Y gas-tric bypass surgery. Am Surg 2006; 72:581-4; discus-sion 584-5.14.Serra C, Baltasar A, Bou R et al. Internal hernias andgastric perforation after a laparoscopic gastric bypass.Obes Surg 1999; 9: 546-9.15.Nguyen NT, Stevens CM, Wolfe BM. Incidence andoutcome of anastomotic stricture after laparoscopicgastric bypass. J Gastrointest Surg 2003; 7: 997-1003;discussion 1003.(Received January 22, 2007; accepted February 18, 2007)

Three-Year Follow-Up Study of Retrocolic versus Antecolic Laparoscopic Roux-en-Y Gastric Bypass

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Three-Year Follow-Up Study of Retrocolic versus Antecolic Laparoscopic Roux-en-Y Gastric Bypass

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