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3-Year Follow-Up Comparing Laparoscopic vs Open GB
Abstract & Commentary
By Namir Katkhouda, MD, FACS, Professor of Surgery, Chief, Minimally Invasive Surgery, University of Southern California (USC)-Los Angeles, CA. Dr. Katkhouda is a consultant for Baxter, Ethicon, Storz, and Gore.
Synopsis: In this randomized trial with a 3-year follow-up, we found that laparoscopic gastric bypass was equally effective as open gastric bypass with respect to weight loss and improvement in comorbidities and quality of life.
Source: Puzziferri N, et al. Three-year follow-up of a prospective randomized trial comparing laparoscopic versus open gastric bypass. Ann Surg. 2006;243:181-188.
Objective: to analyze long-term weight loss, changes in comorbidities and quality of life, and late complications after laparoscopic and open gastric bypass.
Early results from our prospective, randomized trial comparing the outcome of laparoscopic vs open gastric bypass demonstrated less postoperative pain, shorter length of hospital stay, fewer wound-related complications, and faster convalescence for patients who underwent laparoscopic gastric bypass.
Methods: Between May 1999 and March 2001, 155 morbidly obese patients were enrolled in this prospective trial, in which 79 patients were randomized to laparoscopic gastric bypass and 76 to open gastric bypass. Two patients in the laparoscopic group required conversion to open surgery; their data were analyzed within the laparoscopic group on an intention-to-treat basis. The 2 groups were well matched for body mass index, age, and gender. Outcome evaluation included weight loss, changes in comorbidities and quality of life, and late complications.
Results: The mean follow up was 39 ± 8 months. There were no significant differences in the percent of excess body weight loss between the 2 groups at the 3-year follow up (77% for laparoscopic versus 67% for open). The rate of improvement, or resolution, of comorbidities was similar between groups. Improvement in quality of life, measured by the Moorehead-Ardelt Quality of Life Questionnaire, was observed in both groups, without significant differences between groups. Late complications were similar between groups, except for the rate of incisional hernia, which was significantly greater after open gastric bypass (39% versus 5%, P < 0.01), and the rate of cholecystectomy, which was greater after laparoscopic gastric bypass (28% vs 5%, P = 0.03).
Conclusions: In this randomized trial with a 3-year follow-up, we found that laparoscopic gastric bypass was equally effective as open gastric bypass with respect to weight loss and improvement in comorbidities and quality of life. A major advantage at long-term follow-up for patients who underwent laparoscopic gastric bypass was the reduction in the rate of incisional hernia
Puzziferri and colleagues present a very important paper on the follow up of their first study, which showed clearly superior benefits of the laparoscopic approach over the open approach on a short-term follow up. Here they have a follow up of 39 months on 75% of their patients, which is excellent, even if they tend to believe that it is not close to Porries 90 plus over a long period. Many bariatric surgeons would like the same.
In this study, Puzziferri et al show an excellent 77% weight loss and no statistical difference with the open operation. The resolution of comorbidities is the same, and very high, with almost 100% diabetes, which is a logical finding because of the effects of the bypass on the bypassed duodenum, and its implication in the regulation of glucose, following the important work of Francesco Rubino. The main difference is in the rates of incisional hernias, which is very high, as expected in the open group. Of note, the small bowel obstruction rate is similar in both groups, even if some studies have shown recently that the laparoscopic procedure has a slightly higher rate. Finally, only 14% of patients in the laparoscopic group had anemia; none of the patients developed severe malnutrition. This is in accordance with our belief that malnutrition is rare following laparoscopic gastric bypass, provided the patients take their vitamins. This is also due to a natural evolution of the stoma and the pouch, which tend to widen with time, allowing for more food intake.
In summary, this paper proves that the laparoscopic operation is a better option than the open one and should indeed be considered the standard of care for treatment of morbid obesity. As mentioned appropriately in the article, there are no reasons left for the payors to even question this.