Impact of mesenteric defect closure technique on complications after gastric bypass

Impact of mesenteric defect closure technique on complications after gastric bypass Background Closure of mesenteric defects during laparoscopic gastric bypass surgery markedly reduces the risk for small bowel obstruction due to internal hernia. However, this procedure is associated with an increased risk for early small bowel obstruction and pulmonary complication. The purpose of the present study was to evaluate whether the learning curve and subsequent adaptions made to the technique have had an effect on the risk for complications. Methods The results of patients operated with a primary laparoscopic gastric bypass procedure, including closure of the mes- enteric defects with sutures, during a period soon after introduction (January 1, 2010–December 31, 2011) were compared to those of patients operated recently (January 1, 2014–June 30, 2017). Data were retrieved from the Scandinavian Obesity Surgery Registry (SOReg). The main outcome was reoperation for small bowel obstruction within 30 days after surgery. Results A total of 5444 patients were included in the first group (period 1), and 1908 in the second group (period 2). Thirty-day follow-up rates were 97.1 and 97.5% respectively. The risk for early (within 30 days) small bowel obstruction was lower in period 2 than in period 1 (13/1860, 0.7% vs. 67/5285, 1.3%, OR 0.55 (0.30–0.99), p = 0.045). The risk for pulmonary complication was also reduced (5/1860, 0.3%, vs. 41/5285, 0.8%, OR 0.34 (0.14–0.87), p =0.019). Conclusion Closure of mesenteric defects during laparoscopic gastric bypass surgery can be performed safely and should be viewed as a routine part of that operation. . . . Keywords Bariatric surgery Postoperative complication Small bowel obstruction Internal hernia Introduction symptoms, and clinical diagnosis differ from those of postop- erative bowel obstruction in other groups of patients [8–10], Gastric bypass is a well-accepted bariatric surgical method to and delay in diagnosis and treatment may result in devastating markedly reduce the long-term effects of morbid obesity on consequences [10–12]. The risk, however, is markedly reduced cardiovascular disease, cancer development, diabetes, and if mesenteric defects are closed during the laparoscopic gastric quality-of-life [1–4]. The development of a laparoscopic tech- bypass procedure [13]. However, mesenteric defect closure is nique for gastric bypass has improved recovery and reduced associated with an increased risk for early small bowel obstruc- severe postoperative complication and mortality rates [5, 6]. tion due to kinking of the jejunojejunostomy [13]. One compo- With the introduction of laparoscopic gastric bypass surgery, nent of this risk scenario may be a result of being on the early the number of patients suffering from internal hernia with small part of the learning curve. Should this be the case, then this is bowel obstruction increased dramatically [7]. Presentation, perhaps the price we must pay to reduce the long-term risk for internal hernia formation. Since the general introduction of mesenteric defect closure to bariatric surgical practice in Sweden, some adaptions have been made to the procedure in order to reduce the risk for jejunojejunostomy kinking. The * Erik Stenberg purpose of this study was to see if the complication risk related erik.stenberg@regionorebrolan.se to mesenteric defect closure has decreased with time, and to describe possible measures that may be taken in order to further Department of Surgery, Faculty of Medicine and Health, Örebro reduce the risk. University, SE-70185 Örebro, Sweden 482 Langenbecks Arch Surg (2018) 403:481–486 Methods leakage or intraabdominal abscess, bleeding, deep intra- abdominal infection or abscess, gastrointestinal obstruction or Data were collected from the Scandinavian Obesity Surgery ileus, anastomotic stricture, marginal ulcer, port-related compli- Registry (SOReg), a national quality and research registry for cation, cardiovascular event, pulmonary complication (other bariatric surgery covering basically all bariatric surgical pro- than pulmonary embolism), venous thromboembolism, urinary cedures in Sweden [14, 15]. All patients operated with a pri- tract infection, and other (in this case specified) complication. mary laparoscopic gastric bypass procedure between January All postoperative complications were graded according to 1, 2010 and June 30, 2017 were eligible for inclusion in the the Clavien-Dindo scale [17], with any deviance from a nor- study. Retrocolic gastric bypass procedures, non-closure of mal postoperative course considered a postoperative compli- the mesenteric defects, closure with methods other than su- cation. A complication graded as Clavien-Dindo Grade 3b or tures, or method unknown was excluded from the study. Two more (i.e., a complication requiring intervention under general study groups were constructed, one representing the early pe- anesthesia, or resulting in organ failure or death of the patient) riod shortly after introduction of the mesenteric defect closure was considered a serious postoperative complication. technique (January, 1 2010–December 31, 2011: period 1) and one representing the current situation after establishment of Statistical analyses the technique and with adaptions made to the procedure (January 1, 2014–June 30, 2017: period 2). Patients operated The chi-square test was used to evaluate statistical signifi- between these time periods were excluded from the study. cance for categorical variables. Continuous variables were analyzed using the Student t test. Logistic regression was used Surgical technique to evaluate risk for postoperative complication, with odds ra- tios (OR) and 95% confidence intervals (95% CI) as measures The surgical technique for laparoscopic gastric bypass surgery of association. Odds ratios were analyzed unstandardized and is highly standardized in Sweden, with 99% being operated standardized for body mass index, age, and sex. A p value < with the antecolic-antegastric, so-called Lönroth technique 0.05 was considered to be statistically significant. [15, 16]. The technique used for mesenteric defect closure is not so well standardized, but when sutures are used, the mes- Ethical considerations enteric defects beneath the jejunojejunostomy and at Petersen’s space are predominantly closed using running, non-absorbable The study was conducted in accordance with the standards of sutures [13]. The following two links illustrate the technique for the 1964 Helsinki Declaration and its later amendments and closure of the mesenteric defects using non-absorbable sutures. was approved by the Regional Ethics Committee in Uppsala. This is the link to the video demonstrating closure of the mes- enteric defect beneath the jejunojejunostomy: https://s3m.io/ yZTGe. This is the link to the video demonstrating closure of Results Petersen Space: https://s3m.io/RcFQy From January 1, 2010 until December 31, 2011, 5444 primary Definitions laparoscopic gastric bypass procedures with closure of the mesenteric defects using running, non-absorbable sutures Comorbidity was defined as a condition requiring continuous were identified. These patients were included in the introduc- medical treatment or continuous positive airway pressure tion period group (period 1). From January 1, 2014 until June treatment, and specified as sleep apnea, hypertension, diabe- 30, 2017, 1908 primary laparoscopic gastric bypass proce- tes, dyslipidemia, depression, dyspepsia/GERD, or other (in dures with closure of the mesenteric defects using non- this case specified) condition. History of smoking and previ- absorbable sutures were identified. These patients were in- ous venous thromboembolism was registered from May 1, cluded in the established technique group (period 2). Follow-up at 30 days after surgery was registered in the SOReg for 5285 patients during period 1 (97.1%) and 1860 Outcomes during period 2 (97.5%). The main outcome was reoperation for small bowel obstruction occurring within 30 days after surgery. Secondary endpoints Baseline characteristics were the occurrence of any intraoperative adverse event, any postoperative complication, serious postoperative complica- Patients operated during period 1 had a higher BMI and more tion, or specified postoperative complication other than small often comorbid disease than patients operated during period 2 bowel obstruction. Specific complications were anastomotic (Table 1). Preoperative weight reduction was more commonly Langenbecks Arch Surg (2018) 403:481–486 483 Table 1 Baseline characteristics Period 1 (2010–2011) Period 2 (2014–2017) Missing data Missing data No. of individuals, n 5444 1908 BMI, mean ± SD, kg/m 0 42.5 ± 5.36 0 40.2 ± 5.38 Age, mean ± SD, years 0 41.3 ± 10.96 0 40.9 ± 12.02 Comorbidity, n (%) 0 3257 (59.8%) 0 930 (48.7%) Sleep apnea, n (%) 0 727 (13.4%) 0 208 (10.9%) Hypertension, n (%) 0 1533 (28.2%) 0 416 (21.8%) Diabetes, n (%) 0 959 (17.6%) 0 193 (10.1%) Dyslipidemia, n (%) 0 649 (11.9%) 0 139 (7.4%) Dyspepsia/GERD, n (%) 0 826 (15.2%) 0 169 (8.9%) Depression, n (%) 0 819 (15.0%) 0 270 (14.2%) Previous DVT/VTE, n (%) 562 (12.0%) 142 (2.6%) 0 47 (2.5%) employed in period 2 (period 1, n = 4931, 93.9%; period 2, p = 0.111; adjusted OR 0.77 (0.56–1.05), p = 0.098). Small n = 1516, 98.8%; p <0.001). bowel obstruction requiring reoperation was less common during the second period of time (67/5285, 1.3%, vs 13/ 1860, 0.7%, OR 0.55 (0.30–0.99), p = 0.045; adjusted OR Outcome 0.58 (0.32–1.06), p = 0.074). The risk for pulmonary compli- cation was reduced in the second period of time (41/5285, An intraoperative complication occurred in 85 (1.6%) opera- 0.8%, vs 5/1860, 0.3%, OR 0.34 (0.14–0.87), p =0.019; ad- tions during period 1 and in 25 (1.3%) operations during pe- justed OR 0.33 (0–13-0.85), p = 0.021), other specified post- riod 2 (p =0.437). operative complications are presented in Table 2. Postoperative length of stay was on average 1.9 ± 2.57 days in period 1, and 1.6 ± 1.68 days in period 2 (p <0.001). In all, 431 (8.2%) patients suffered from any complication during period 1, and 129 (6.9%) during period 2 (OR 0.84 Discussion (0.68–1.03), p = 0.092; adjusted OR 0.82 (0.67–1.01), p = 0.068). A serious postoperative complication occurred after Closure of the mesenteric defects using non-absorbable running 192 (3.6%) operations performed during period 1 and after sutures is known to reduce the risk for internal hernia and small 46 (2.8%) operations during period 2 (OR 0.78 (0.57–1.06), bowel obstruction after laparoscopic gastric bypass surgery [13, Table 2 Specified postoperative Period 1 (2010–2011) Period 2 (2014–2017) p complications Complications, n (%) Complications, n (%) No. of individuals, n 5285 1860 Any complication 431 (8.2%) 129 (6.9%) 0.092 Leak/intra-abdominal abscess 76 (1.4%) 14 (0.8%) 0.023 SBO/paralysis 72 (1.4%) 18 (1.0%) 0.189 Bleeding 110 (2.1%) 26 (1.4%) 0.064 Other wound complication 38 (0.7%) 12 (0.6%) 0.742 Port-related complication 29 (0.5%) 2 (0.1%) 0.013 Stricture 17 (0.3%) 2 (0.1%) 0.123 Marginal ulcer 23 (0.4%) 7 (0.4%) 0.736 Cardiovascular complication 15 (0.3%) 2 (0.1%) 0.180 Pulmonary complication 41 (0.8%) 5 (0.3%) 0.019 DVT/VTE 5 (0.1%) 2 (0.1%) 1.000 Urinary tract infection 20 (0.4%) 7 (0.4%) 0.990 Other complication 83 (1.6%) 43 (2.3%) 0.037 Including all cases of bowel obstruction and paralysis (grades I–Vaccording to the Clavien-Dindo classification) 484 Langenbecks Arch Surg (2018) 403:481–486 18, 19]. When introducing this technique, there was an associ- day. The present study comparing outcomes before and after ated increased risk for early small bowel obstruction, mainly introduction of mesenteric defect closure provides some support due to kinking of the jejunojejunostomy, and also for pulmo- for these adaptions, and they can therefore be recommended. We nary complication [13]. With time, reoperation due to small also noted an increase in the application of preoperative weight bowel obstruction during the first 30 days after surgery has loss between periods 1 and 2. This measure reduces the risk for become less common than it was initially when introducing postoperative complications after laparoscopic gastric bypass the mesenteric defect closure with suture technique in surgery [23] and is also associated with better postoperative Sweden. The risk for pulmonary complication has also fallen. weight loss [24]. Furthermore, it has the benefit of reducing liver Many of the safety issues related to the suture technique may size and intra-abdominal fat, thus providing better visibility dur- thus be attributed to a learning curve effect. However, over ing surgery [25], and significant preoperative weight loss makes time, a few adaptions have been made to the technique to re- it much easier to gain access to the mesenteric defects and there- duce the risk for kinking of the jejunojejunostomy. Any adap- fore enables better and safer closure. Preoperative weight loss is tion to an established surgical procedure should preferably be now widely accepted in Sweden [15]. assessed as part of a clinical trial [20]. Unfortunately, most There are other techniques described that may help reduc- adaptions have never been evaluated and scientific support for ing the risk for kinking of the jejunojejunostomy as well. these is therefore weak [21, 22]. Bearing this in mind, some Double-stapling of the anastomosis may reduce the risk for adaptions have reached wide acceptance within the Swedish early small bowel obstruction at the price of a slight increase surgical community and have possibly contributed to the reduc- in gastrointestinal bleeding [26]. An antiobstructive stitch has tion in the number of complications associated with closure of also been reported to have a potential preventive effect in open mesenteric defects with running, non-absorbable sutures. gastric bypass surgery [27]. The scientific support for these Routine division of the mesentery at the site of the blind limb measures are however still weak, and although they have next to the jejunojejunostomy (Fig. 1) is now widely accepted in reached some acceptance in Sweden, they are still only used Sweden [18]. The benefit of this additional step is that it creates a on an occasional basis. mobile jejunojejunostomy, located well beneath the transverse The present study was a comparison between the outcomes colon. This may help to reduce the strain on the anastomosis. of operations performed during two separate periods in time. Furthermore, with experience, many surgeons have learned to Time generally leads to improvement in the quality and results pay close attention to the sutures placed at the top of the mes- of bariatric surgery [28] and this is perhaps the main limitation of enteric defect beneath the jejunojejunostomy (Fig. 1). The su- this study. Any trial comparing surgical outcome of procedures tures placed close to the bowel may result in narrowing or performed during different periods in time can never exclude the kinking of the anastomosis, if these sutures are placed in a impact of time itself—or rather the small unobserved improve- ments made over time. The main purpose of this trial, however, non-correct manner. If these sutures are placed correctly, the anastomosis will appear harmonic and the risk for kinking of was to evaluate the effect of experience in mesenteric defect the anastomosis will probably be reduced. A critical assessment closure on the early complication rate after bariatric surgery. of these adaptions should be made within the framework of a Increased experience is likely to be one of the major factors clinical trial. However, it is unlikely that any trial with enough contributing to the improvement of results over time. Since we power to perform such an evaluation will ever see the light of did not have information on individual surgeons, all analyses were made on a national level. The patients operated in period 2 had, on average, a lower BMI and less comorbid disease. They thus represent a slightly different group of patients than those operated within period 1. Significant early weight loss, younger age, and less comorbid disease are associated with the develop- ment of internal hernia [13]. This would imply that the healthier patients operated during period 2 were at higher risk for bowel obstructioncomparedtopatientsoperatedduringperiod1.In order to compensate for this difference, an adjusted logistic re- gression model was adapted. Within this model, the difference in reoperations for small bowel obstruction in the early postopera- tive period was no longer statistically significant. We can there- fore not fully exclude that part of the difference between the two periods of time may be due to differences in patient characteris- tics. Finally, another limitation of this study is that many of the patients were operated outside the framework of a clinical trial Fig. 1 Photo illustrating closure of the mesenteric defect beneath the jejunojejunostomy and as a result, the technique for mesenteric defect closure was Langenbecks Arch Surg (2018) 403:481–486 485 after bariatric surgery. N Engl J Med 351(26):2683–2693. https:// not standard. The surgical technique for laparoscopic gastric doi.org/10.1056/NEJMoa035622 bypass surgery, however, is well standardized in Sweden today, 2. Schauer PR, Kashyap SR, Wolski K, Brethauer SA, Kirwan JP, and when the mesenteric defects are closed with sutures, most Pothier CE, Thomas S, Abood B, Nissen SE, Bhatt DL (2012) surgeons close the mesenteric defects with the same technique Bariatric surgery versus intensive medical therapy in obese patients with diabetes. N Engl J Med 366(17):1567–1576. https://doi.org/ [13]. Furthermore, the effects of mesenteric defect closure in 10.1056/NEJMoa1200225 general surgical practice is also well documented [29]. 3. Mingrone G, Panunzi S, De Gaetano A, Guidone C, Iaconelli A, Although routine closure of the mesenteric defects is well ac- Leccesi L, Nanni G, Pomp A, Castagneto M, Ghirlanda G, Rubino cepted throughout Sweden today, many centers have shifted F (2012) Bariatric surgery versus conventional medical therapy for type 2 diabetes. N Engl J Med 366(17):1577–1585. https://doi.org/ their preference to metal clips instead of running, non- 10.1056/NEJMoa1200111 absorbable sutures over more recent years which explains the 4. Sjostrom L, Gummesson A, Sjostrom CD, Narbro K, Peltonen M, lower numbers during the second period. Whether or not this Wedel H, Bengtsson C, Bouchard C, Carlsson B, Dahlgren S, method is equally efficient and safe remains to be seen. Jacobson P, Karason K, Karlsson J, Larsson B, Lindroos AK, Closure of the mesenteric defects during laparoscopic gas- Lonroth H, Naslund I, Olbers T, Stenlof K, Torgerson J, Carlsson LM, Swedish Obese Subjects S (2009) Effects of bariatric surgery tric bypass surgery should be viewed as a routine part of the on cancer incidence in obese patients in Sweden (Swedish Obese procedure to reduce the risk for internal herniation with small Subjects Study): a prospective, controlled intervention trial. Lancet bowel obstruction. We have seen that once the learning curve Oncol 10(7):653–662. https://doi.org/10.1016/S1470-2045(09) phase has passed and adaptions are made, this technique may 70159-7 5. Hutter MM, Randall S, Khuri SF, Henderson WG, Abbott WM, be safely performed. Warshaw AL (2006) Laparoscopic versus open gastric bypass for morbid obesity: a multicenter, prospective, risk-adjusted analysis Authors’ contributions Study conception and design—Erik Stenberg from the National Surgical Quality Improvement Program. Ann Acquisition of data—Erik Stenberg, Ingmar Näslund, Eva Szabo, Surg 243(5):657–662. https://doi.org/10.1097/01.sla.0000216784. Johan Ottosson 05951.0b Analysis and interpretation of data—Erik Stenberg, Ingmar Näslund, 6. Puzziferri N, Austrheim-Smith IT, Wolfe BM, Wilson SE, Nguyen Eva Szabo, Johan Ottosson NT (2006) Three-year follow-up of a prospective randomized trial Drafting of manuscript—Erik Stenberg comparing laparoscopic versus open gastric bypass. Ann Surg Critical revision of manuscript—Ingmar Näslund, Eva Szabo, Johan 243(2):181–188. https://doi.org/10.1097/01.sla.0000197381. Ottosson 01214.76 7. Abasbassi M, Pottel H, Deylgat B, Vansteenkiste F, Van Rooy F, Funding This work was supported by grants from the Örebro County Devriendt D, D'Hondt M (2011) Small bowel obstruction after council and Örebro University. antecolic antegastric laparoscopic Roux-en-Y gastric bypass with- out division of small bowel mesentery: a single-centre, 7-year re- view. Obes Surg 21(12):1822–1827. https://doi.org/10.1007/ Compliance with ethical standards s11695-011-0462-6 8. Geubbels N, Lijftogt N, Fiocco M, van Leersum NJ, Wouters MW, Conflict of interest Ingmar Näslund has received consultant fees from de Brauw LM (2015) Meta-analysis of internal herniation after Baricol Bariatrics AB, Sweden. None of the other authors declares any gastric bypass surgery. Br J Surg 102(5):451–460. https://doi.org/ conflict of interest. 10.1002/bjs.9738 9. 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N Engl J Med 351(7): Commons Attribution 4.0 International License (http:// 721–722. https://doi.org/10.1056/NEJM200408123510722 creativecommons.org/licenses/by/4.0/), which permits unrestricted use, 12. Efthimiou E, Stein L, Court O, Christou N (2009) Internal hernia distribution, and reproduction in any medium, provided you give appro- after gastric bypass surgery during middle trimester pregnancy priate credit to the original author(s) and the source, provide a link to the resulting in fetal loss: risk of internal hernia never ends. Surg Creative Commons license, and indicate if changes were made. Obes Relat Dis 5(3):378–380. https://doi.org/10.1016/j.soard. 2008.09.003 13. Stenberg E, Szabo E, Agren G, Ottosson J, Marsk R, Lonroth H, Boman L, Magnuson A, Thorell A, Naslund I (2016) Closure of References mesenteric defects in laparoscopic gastric bypass: a multicentre, randomised, parallel, open-label trial. 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Impact of mesenteric defect closure technique on complications after gastric bypass

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Medicine & Public Health; General Surgery; Abdominal Surgery; Cardiac Surgery; Thoracic Surgery; Traumatic Surgery; Vascular Surgery
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Abstract

Background Closure of mesenteric defects during laparoscopic gastric bypass surgery markedly reduces the risk for small bowel obstruction due to internal hernia. However, this procedure is associated with an increased risk for early small bowel obstruction and pulmonary complication. The purpose of the present study was to evaluate whether the learning curve and subsequent adaptions made to the technique have had an effect on the risk for complications. Methods The results of patients operated with a primary laparoscopic gastric bypass procedure, including closure of the mes- enteric defects with sutures, during a period soon after introduction (January 1, 2010–December 31, 2011) were compared to those of patients operated recently (January 1, 2014–June 30, 2017). Data were retrieved from the Scandinavian Obesity Surgery Registry (SOReg). The main outcome was reoperation for small bowel obstruction within 30 days after surgery. Results A total of 5444 patients were included in the first group (period 1), and 1908 in the second group (period 2). Thirty-day follow-up rates were 97.1 and 97.5% respectively. The risk for early (within 30 days) small bowel obstruction was lower in period 2 than in period 1 (13/1860, 0.7% vs. 67/5285, 1.3%, OR 0.55 (0.30–0.99), p = 0.045). The risk for pulmonary complication was also reduced (5/1860, 0.3%, vs. 41/5285, 0.8%, OR 0.34 (0.14–0.87), p =0.019). Conclusion Closure of mesenteric defects during laparoscopic gastric bypass surgery can be performed safely and should be viewed as a routine part of that operation. . . . Keywords Bariatric surgery Postoperative complication Small bowel obstruction Internal hernia Introduction symptoms, and clinical diagnosis differ from those of postop- erative bowel obstruction in other groups of patients [8–10], Gastric bypass is a well-accepted bariatric surgical method to and delay in diagnosis and treatment may result in devastating markedly reduce the long-term effects of morbid obesity on consequences [10–12]. The risk, however, is markedly reduced cardiovascular disease, cancer development, diabetes, and if mesenteric defects are closed during the laparoscopic gastric quality-of-life [1–4]. The development of a laparoscopic tech- bypass procedure [13]. However, mesenteric defect closure is nique for gastric bypass has improved recovery and reduced associated with an increased risk for early small bowel obstruc- severe postoperative complication and mortality rates [5, 6]. tion due to kinking of the jejunojejunostomy [13]. One compo- With the introduction of laparoscopic gastric bypass surgery, nent of this risk scenario may be a result of being on the early the number of patients suffering from internal hernia with small part of the learning curve. Should this be the case, then this is bowel obstruction increased dramatically [7]. Presentation, perhaps the price we must pay to reduce the long-term risk for internal hernia formation. Since the general introduction of mesenteric defect closure to bariatric surgical practice in Sweden, some adaptions have been made to the procedure in order to reduce the risk for jejunojejunostomy kinking. The * Erik Stenberg purpose of this study was to see if the complication risk related erik.stenberg@regionorebrolan.se to mesenteric defect closure has decreased with time, and to describe possible measures that may be taken in order to further Department of Surgery, Faculty of Medicine and Health, Örebro reduce the risk. University, SE-70185 Örebro, Sweden 482 Langenbecks Arch Surg (2018) 403:481–486 Methods leakage or intraabdominal abscess, bleeding, deep intra- abdominal infection or abscess, gastrointestinal obstruction or Data were collected from the Scandinavian Obesity Surgery ileus, anastomotic stricture, marginal ulcer, port-related compli- Registry (SOReg), a national quality and research registry for cation, cardiovascular event, pulmonary complication (other bariatric surgery covering basically all bariatric surgical pro- than pulmonary embolism), venous thromboembolism, urinary cedures in Sweden [14, 15]. All patients operated with a pri- tract infection, and other (in this case specified) complication. mary laparoscopic gastric bypass procedure between January All postoperative complications were graded according to 1, 2010 and June 30, 2017 were eligible for inclusion in the the Clavien-Dindo scale [17], with any deviance from a nor- study. Retrocolic gastric bypass procedures, non-closure of mal postoperative course considered a postoperative compli- the mesenteric defects, closure with methods other than su- cation. A complication graded as Clavien-Dindo Grade 3b or tures, or method unknown was excluded from the study. Two more (i.e., a complication requiring intervention under general study groups were constructed, one representing the early pe- anesthesia, or resulting in organ failure or death of the patient) riod shortly after introduction of the mesenteric defect closure was considered a serious postoperative complication. technique (January, 1 2010–December 31, 2011: period 1) and one representing the current situation after establishment of Statistical analyses the technique and with adaptions made to the procedure (January 1, 2014–June 30, 2017: period 2). Patients operated The chi-square test was used to evaluate statistical signifi- between these time periods were excluded from the study. cance for categorical variables. Continuous variables were analyzed using the Student t test. Logistic regression was used Surgical technique to evaluate risk for postoperative complication, with odds ra- tios (OR) and 95% confidence intervals (95% CI) as measures The surgical technique for laparoscopic gastric bypass surgery of association. Odds ratios were analyzed unstandardized and is highly standardized in Sweden, with 99% being operated standardized for body mass index, age, and sex. A p value < with the antecolic-antegastric, so-called Lönroth technique 0.05 was considered to be statistically significant. [15, 16]. The technique used for mesenteric defect closure is not so well standardized, but when sutures are used, the mes- Ethical considerations enteric defects beneath the jejunojejunostomy and at Petersen’s space are predominantly closed using running, non-absorbable The study was conducted in accordance with the standards of sutures [13]. The following two links illustrate the technique for the 1964 Helsinki Declaration and its later amendments and closure of the mesenteric defects using non-absorbable sutures. was approved by the Regional Ethics Committee in Uppsala. This is the link to the video demonstrating closure of the mes- enteric defect beneath the jejunojejunostomy: https://s3m.io/ yZTGe. This is the link to the video demonstrating closure of Results Petersen Space: https://s3m.io/RcFQy From January 1, 2010 until December 31, 2011, 5444 primary Definitions laparoscopic gastric bypass procedures with closure of the mesenteric defects using running, non-absorbable sutures Comorbidity was defined as a condition requiring continuous were identified. These patients were included in the introduc- medical treatment or continuous positive airway pressure tion period group (period 1). From January 1, 2014 until June treatment, and specified as sleep apnea, hypertension, diabe- 30, 2017, 1908 primary laparoscopic gastric bypass proce- tes, dyslipidemia, depression, dyspepsia/GERD, or other (in dures with closure of the mesenteric defects using non- this case specified) condition. History of smoking and previ- absorbable sutures were identified. These patients were in- ous venous thromboembolism was registered from May 1, cluded in the established technique group (period 2). Follow-up at 30 days after surgery was registered in the SOReg for 5285 patients during period 1 (97.1%) and 1860 Outcomes during period 2 (97.5%). The main outcome was reoperation for small bowel obstruction occurring within 30 days after surgery. Secondary endpoints Baseline characteristics were the occurrence of any intraoperative adverse event, any postoperative complication, serious postoperative complica- Patients operated during period 1 had a higher BMI and more tion, or specified postoperative complication other than small often comorbid disease than patients operated during period 2 bowel obstruction. Specific complications were anastomotic (Table 1). Preoperative weight reduction was more commonly Langenbecks Arch Surg (2018) 403:481–486 483 Table 1 Baseline characteristics Period 1 (2010–2011) Period 2 (2014–2017) Missing data Missing data No. of individuals, n 5444 1908 BMI, mean ± SD, kg/m 0 42.5 ± 5.36 0 40.2 ± 5.38 Age, mean ± SD, years 0 41.3 ± 10.96 0 40.9 ± 12.02 Comorbidity, n (%) 0 3257 (59.8%) 0 930 (48.7%) Sleep apnea, n (%) 0 727 (13.4%) 0 208 (10.9%) Hypertension, n (%) 0 1533 (28.2%) 0 416 (21.8%) Diabetes, n (%) 0 959 (17.6%) 0 193 (10.1%) Dyslipidemia, n (%) 0 649 (11.9%) 0 139 (7.4%) Dyspepsia/GERD, n (%) 0 826 (15.2%) 0 169 (8.9%) Depression, n (%) 0 819 (15.0%) 0 270 (14.2%) Previous DVT/VTE, n (%) 562 (12.0%) 142 (2.6%) 0 47 (2.5%) employed in period 2 (period 1, n = 4931, 93.9%; period 2, p = 0.111; adjusted OR 0.77 (0.56–1.05), p = 0.098). Small n = 1516, 98.8%; p <0.001). bowel obstruction requiring reoperation was less common during the second period of time (67/5285, 1.3%, vs 13/ 1860, 0.7%, OR 0.55 (0.30–0.99), p = 0.045; adjusted OR Outcome 0.58 (0.32–1.06), p = 0.074). The risk for pulmonary compli- cation was reduced in the second period of time (41/5285, An intraoperative complication occurred in 85 (1.6%) opera- 0.8%, vs 5/1860, 0.3%, OR 0.34 (0.14–0.87), p =0.019; ad- tions during period 1 and in 25 (1.3%) operations during pe- justed OR 0.33 (0–13-0.85), p = 0.021), other specified post- riod 2 (p =0.437). operative complications are presented in Table 2. Postoperative length of stay was on average 1.9 ± 2.57 days in period 1, and 1.6 ± 1.68 days in period 2 (p <0.001). In all, 431 (8.2%) patients suffered from any complication during period 1, and 129 (6.9%) during period 2 (OR 0.84 Discussion (0.68–1.03), p = 0.092; adjusted OR 0.82 (0.67–1.01), p = 0.068). A serious postoperative complication occurred after Closure of the mesenteric defects using non-absorbable running 192 (3.6%) operations performed during period 1 and after sutures is known to reduce the risk for internal hernia and small 46 (2.8%) operations during period 2 (OR 0.78 (0.57–1.06), bowel obstruction after laparoscopic gastric bypass surgery [13, Table 2 Specified postoperative Period 1 (2010–2011) Period 2 (2014–2017) p complications Complications, n (%) Complications, n (%) No. of individuals, n 5285 1860 Any complication 431 (8.2%) 129 (6.9%) 0.092 Leak/intra-abdominal abscess 76 (1.4%) 14 (0.8%) 0.023 SBO/paralysis 72 (1.4%) 18 (1.0%) 0.189 Bleeding 110 (2.1%) 26 (1.4%) 0.064 Other wound complication 38 (0.7%) 12 (0.6%) 0.742 Port-related complication 29 (0.5%) 2 (0.1%) 0.013 Stricture 17 (0.3%) 2 (0.1%) 0.123 Marginal ulcer 23 (0.4%) 7 (0.4%) 0.736 Cardiovascular complication 15 (0.3%) 2 (0.1%) 0.180 Pulmonary complication 41 (0.8%) 5 (0.3%) 0.019 DVT/VTE 5 (0.1%) 2 (0.1%) 1.000 Urinary tract infection 20 (0.4%) 7 (0.4%) 0.990 Other complication 83 (1.6%) 43 (2.3%) 0.037 Including all cases of bowel obstruction and paralysis (grades I–Vaccording to the Clavien-Dindo classification) 484 Langenbecks Arch Surg (2018) 403:481–486 18, 19]. When introducing this technique, there was an associ- day. The present study comparing outcomes before and after ated increased risk for early small bowel obstruction, mainly introduction of mesenteric defect closure provides some support due to kinking of the jejunojejunostomy, and also for pulmo- for these adaptions, and they can therefore be recommended. We nary complication [13]. With time, reoperation due to small also noted an increase in the application of preoperative weight bowel obstruction during the first 30 days after surgery has loss between periods 1 and 2. This measure reduces the risk for become less common than it was initially when introducing postoperative complications after laparoscopic gastric bypass the mesenteric defect closure with suture technique in surgery [23] and is also associated with better postoperative Sweden. The risk for pulmonary complication has also fallen. weight loss [24]. Furthermore, it has the benefit of reducing liver Many of the safety issues related to the suture technique may size and intra-abdominal fat, thus providing better visibility dur- thus be attributed to a learning curve effect. However, over ing surgery [25], and significant preoperative weight loss makes time, a few adaptions have been made to the technique to re- it much easier to gain access to the mesenteric defects and there- duce the risk for kinking of the jejunojejunostomy. Any adap- fore enables better and safer closure. Preoperative weight loss is tion to an established surgical procedure should preferably be now widely accepted in Sweden [15]. assessed as part of a clinical trial [20]. Unfortunately, most There are other techniques described that may help reduc- adaptions have never been evaluated and scientific support for ing the risk for kinking of the jejunojejunostomy as well. these is therefore weak [21, 22]. Bearing this in mind, some Double-stapling of the anastomosis may reduce the risk for adaptions have reached wide acceptance within the Swedish early small bowel obstruction at the price of a slight increase surgical community and have possibly contributed to the reduc- in gastrointestinal bleeding [26]. An antiobstructive stitch has tion in the number of complications associated with closure of also been reported to have a potential preventive effect in open mesenteric defects with running, non-absorbable sutures. gastric bypass surgery [27]. The scientific support for these Routine division of the mesentery at the site of the blind limb measures are however still weak, and although they have next to the jejunojejunostomy (Fig. 1) is now widely accepted in reached some acceptance in Sweden, they are still only used Sweden [18]. The benefit of this additional step is that it creates a on an occasional basis. mobile jejunojejunostomy, located well beneath the transverse The present study was a comparison between the outcomes colon. This may help to reduce the strain on the anastomosis. of operations performed during two separate periods in time. Furthermore, with experience, many surgeons have learned to Time generally leads to improvement in the quality and results pay close attention to the sutures placed at the top of the mes- of bariatric surgery [28] and this is perhaps the main limitation of enteric defect beneath the jejunojejunostomy (Fig. 1). The su- this study. Any trial comparing surgical outcome of procedures tures placed close to the bowel may result in narrowing or performed during different periods in time can never exclude the kinking of the anastomosis, if these sutures are placed in a impact of time itself—or rather the small unobserved improve- ments made over time. The main purpose of this trial, however, non-correct manner. If these sutures are placed correctly, the anastomosis will appear harmonic and the risk for kinking of was to evaluate the effect of experience in mesenteric defect the anastomosis will probably be reduced. A critical assessment closure on the early complication rate after bariatric surgery. of these adaptions should be made within the framework of a Increased experience is likely to be one of the major factors clinical trial. However, it is unlikely that any trial with enough contributing to the improvement of results over time. Since we power to perform such an evaluation will ever see the light of did not have information on individual surgeons, all analyses were made on a national level. The patients operated in period 2 had, on average, a lower BMI and less comorbid disease. They thus represent a slightly different group of patients than those operated within period 1. Significant early weight loss, younger age, and less comorbid disease are associated with the develop- ment of internal hernia [13]. This would imply that the healthier patients operated during period 2 were at higher risk for bowel obstructioncomparedtopatientsoperatedduringperiod1.In order to compensate for this difference, an adjusted logistic re- gression model was adapted. Within this model, the difference in reoperations for small bowel obstruction in the early postopera- tive period was no longer statistically significant. We can there- fore not fully exclude that part of the difference between the two periods of time may be due to differences in patient characteris- tics. Finally, another limitation of this study is that many of the patients were operated outside the framework of a clinical trial Fig. 1 Photo illustrating closure of the mesenteric defect beneath the jejunojejunostomy and as a result, the technique for mesenteric defect closure was Langenbecks Arch Surg (2018) 403:481–486 485 after bariatric surgery. N Engl J Med 351(26):2683–2693. https:// not standard. The surgical technique for laparoscopic gastric doi.org/10.1056/NEJMoa035622 bypass surgery, however, is well standardized in Sweden today, 2. Schauer PR, Kashyap SR, Wolski K, Brethauer SA, Kirwan JP, and when the mesenteric defects are closed with sutures, most Pothier CE, Thomas S, Abood B, Nissen SE, Bhatt DL (2012) surgeons close the mesenteric defects with the same technique Bariatric surgery versus intensive medical therapy in obese patients with diabetes. N Engl J Med 366(17):1567–1576. https://doi.org/ [13]. Furthermore, the effects of mesenteric defect closure in 10.1056/NEJMoa1200225 general surgical practice is also well documented [29]. 3. Mingrone G, Panunzi S, De Gaetano A, Guidone C, Iaconelli A, Although routine closure of the mesenteric defects is well ac- Leccesi L, Nanni G, Pomp A, Castagneto M, Ghirlanda G, Rubino cepted throughout Sweden today, many centers have shifted F (2012) Bariatric surgery versus conventional medical therapy for type 2 diabetes. N Engl J Med 366(17):1577–1585. https://doi.org/ their preference to metal clips instead of running, non- 10.1056/NEJMoa1200111 absorbable sutures over more recent years which explains the 4. Sjostrom L, Gummesson A, Sjostrom CD, Narbro K, Peltonen M, lower numbers during the second period. Whether or not this Wedel H, Bengtsson C, Bouchard C, Carlsson B, Dahlgren S, method is equally efficient and safe remains to be seen. Jacobson P, Karason K, Karlsson J, Larsson B, Lindroos AK, Closure of the mesenteric defects during laparoscopic gas- Lonroth H, Naslund I, Olbers T, Stenlof K, Torgerson J, Carlsson LM, Swedish Obese Subjects S (2009) Effects of bariatric surgery tric bypass surgery should be viewed as a routine part of the on cancer incidence in obese patients in Sweden (Swedish Obese procedure to reduce the risk for internal herniation with small Subjects Study): a prospective, controlled intervention trial. Lancet bowel obstruction. We have seen that once the learning curve Oncol 10(7):653–662. https://doi.org/10.1016/S1470-2045(09) phase has passed and adaptions are made, this technique may 70159-7 5. Hutter MM, Randall S, Khuri SF, Henderson WG, Abbott WM, be safely performed. Warshaw AL (2006) Laparoscopic versus open gastric bypass for morbid obesity: a multicenter, prospective, risk-adjusted analysis Authors’ contributions Study conception and design—Erik Stenberg from the National Surgical Quality Improvement Program. Ann Acquisition of data—Erik Stenberg, Ingmar Näslund, Eva Szabo, Surg 243(5):657–662. https://doi.org/10.1097/01.sla.0000216784. Johan Ottosson 05951.0b Analysis and interpretation of data—Erik Stenberg, Ingmar Näslund, 6. Puzziferri N, Austrheim-Smith IT, Wolfe BM, Wilson SE, Nguyen Eva Szabo, Johan Ottosson NT (2006) Three-year follow-up of a prospective randomized trial Drafting of manuscript—Erik Stenberg comparing laparoscopic versus open gastric bypass. Ann Surg Critical revision of manuscript—Ingmar Näslund, Eva Szabo, Johan 243(2):181–188. https://doi.org/10.1097/01.sla.0000197381. Ottosson 01214.76 7. Abasbassi M, Pottel H, Deylgat B, Vansteenkiste F, Van Rooy F, Funding This work was supported by grants from the Örebro County Devriendt D, D'Hondt M (2011) Small bowel obstruction after council and Örebro University. antecolic antegastric laparoscopic Roux-en-Y gastric bypass with- out division of small bowel mesentery: a single-centre, 7-year re- view. Obes Surg 21(12):1822–1827. https://doi.org/10.1007/ Compliance with ethical standards s11695-011-0462-6 8. Geubbels N, Lijftogt N, Fiocco M, van Leersum NJ, Wouters MW, Conflict of interest Ingmar Näslund has received consultant fees from de Brauw LM (2015) Meta-analysis of internal herniation after Baricol Bariatrics AB, Sweden. None of the other authors declares any gastric bypass surgery. Br J Surg 102(5):451–460. https://doi.org/ conflict of interest. 10.1002/bjs.9738 9. 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Langenbeck's Archives of SurgerySpringer Journals

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