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Obesity Surgery

, Volume 19, Issue 4, pp 412–417 | Cite as

Vagal Nerve Dissection During Pouch Formation in Laparoscopic Roux-Y-Gastric Bypass for Technical Simplification: Does it Matter?

  • A. Perathoner
  • H. Weiss
  • W. Santner
  • G. Brandacher
  • E. Laimer
  • E. Höller
  • F. Aigner
  • A. KlausEmail author
Research Article

Abstract

Background

In Roux-Y gastric bypass surgery pouch formation is the most demanding part of the operation. The vagal nerve is usually tempted to be preserved although results reporting beneficial effects are lacking. Dividing the perigastric tissue including the anterior vagal trunk may technically alleviate gastric pouch formation. We evaluated the clinical outcome in patients with and without vagal nerve dissection in patients after Roux-Y gastric bypass (RY-BP).

Methods

In this study 40 morbidly obese patients undergoing RY-BP have been included. Patients were divided into two groups according to vagal nerve preservation (Group 1, n = 25) or vagal nerve dissection (Group 2, n = 22). Clinical parameters (weight loss, complications, gastrointestinal symptoms), esophageal endoscopy, and motility data (manometry, pH-metry) and a satiety score were assessed. Serum values of ghrelin and gastrin were measured.

Results

All procedures were performed by laparoscopy with a 0% mortality rate. One patient of each groups necessitated redo-laparoscopy (bleeding and a lost drainage). All patients significantly reduced body weight (p < 0.01 compared to preoperative) during a median follow-up of 36.1 months. Two patients of Group 2 showed acid reflux demonstrated by pathologic postoperative DeMeester scores. Esophageal body peristalsis and barium swallows did not reveal statistically significant differences between the two groups. Parameters of satiety assessment did not differ between the two groups as did serum values of gastrin and ghrelin.

Conclusion

Pouch formation during RY-BP may be alleviated by simply dissecting the perigastric fatty tissue. In this way the anterior vagal trunk is dissected, however, no influence on clinical, functional and laboratory results occur.

Keywords

Gastric bypass Vagal nerve Bariatric surgery Technique 

References

  1. 1.
    Suter M, Paroz A, Calmes JM, et al. European experience with laparoscopic Roux-en-Y bypass in 466 obese patients. Br J Surg 2006;93(6):726–32. Jun.CrossRefGoogle Scholar
  2. 2.
    Müller MK, Guber J, Wildi S, et al. Three-year-follow-up study of retrocolic versus antecolic laparoscopic Roux-en-Y gastric bypass. Obes Surg 2007;17(7):889–93. Jul.CrossRefGoogle Scholar
  3. 3.
    le Roux CW, Welbourn R, Werling M, et al. Gut hormones as mediators of appetite and weight loss after Roux-en-Y gastric bypass. Ann Surg 2007;246:780–5. Nov.CrossRefGoogle Scholar
  4. 4.
    Weiner S, Sauerland S, Fein M, et al. The bariatric quality of life index: a measure of well-being in obesity surgery patients. Obes Surg 2005;15(4):538–45. Apr.CrossRefGoogle Scholar
  5. 5.
    Adams T. Long-term mortality after gastric bypass surgery. N Engl J Med 2007;357:753–61. Aug 23.CrossRefGoogle Scholar
  6. 6.
    Lee H, Te C, Koshy S, et al. Does Ghrelin really matter after bariatric surgery? Surg Obes Relat Dis 2006;2:538–48.CrossRefGoogle Scholar
  7. 7.
    Asakawa A, Inui A, Kaga T, et al. Ghrelin is an appetite-stimulatory signal from stomach with structural resemblance to motilin. Gastroenterology 2001;120:337–45.CrossRefGoogle Scholar
  8. 8.
    Date Y, Murakami N, Toshinai K, et al. The role of the gastric afferent vagal nerve in ghrelin-indiced feeding and growth hormone secretion in rats. Gastroenterology 2002;123:1120–8.CrossRefGoogle Scholar
  9. 9.
    Frühbeck G, Rotellar F, Hernandez-Lizoain JL, et al. Fasting plasma ghrelin concentrations 6 months after gastric bypass are not determined by weight loss or changes in insulinemia. Obes Surg 2004;14:1208–15.CrossRefGoogle Scholar
  10. 10.
    Maier C, Schaller G, Buranyi B, et al. The cholinergic system controls ghrelin release and ghrelin-induced growth hormone release in humans. J Clin Endocrinol Metab 2004;89:4729–33.CrossRefGoogle Scholar
  11. 11.
    Arosio M, Ronchi CL, Beck-Peccoz P, et al. Effects of modified sham feeding on ghrelin levels in healthy human subjects. J Clin Endocrinol Metab 2004;89:5101–4.CrossRefGoogle Scholar
  12. 12.
    Simonian HP, Kresge KM, Boden GH, et al. Differential effects of sham feeding and meal ingestion on ghrelin and pancreatic polypeptide levels: evidence for vagal efferent stimulation mediating ghrelin release. Neurogastroenterol Motil 2005;17:348–54.CrossRefGoogle Scholar
  13. 13.
    Pudel D, Westenhöfer J. Fragebogen zum Essverhalten (FEV). Handanweisung, Göttingen: Hogrefep. 1989.Google Scholar
  14. 14.
    Weiss HG, Nehoda H, Labeck B, et al. Treatment of morbid obesity with laparoscopic adjustable gastric banding affects esophageal motility. Am J Surg 2000;180(6):479–82. Dec.CrossRefGoogle Scholar
  15. 15.
    Hinder RA, Filipi CJ, Wetscher G, et al. Laparoscopic Nissen fundoplication is an effective treatment for gastroesophageal reflux disease. Ann Surg 1994;220:472–83.CrossRefGoogle Scholar
  16. 16.
    Wetscher GJ, Gadenstaetter M, Klingler PJ, et al. Efficacy of medical therapy and antireflux surgery to prevent Barrett’s metaplasia in patients with gastroesophageal reflux disease. Ann Surg 2001;234:627–32.CrossRefGoogle Scholar
  17. 17.
    DeMeester TR, Wang CI, Wernly JA, et al. Technique, indications and clinical use of 24-hour esophageal pH monitoring. J Thorac Cardiovasc Surg 1980;79:656–70.PubMedGoogle Scholar
  18. 18.
    Livingston EH, Elliott AC, Hynan LS, et al. When policy meets statistics: the very real effect that questionable statistical analysis has on limiting health care access for bariatric surgery. Arch Surg 2007;142:979–87.CrossRefGoogle Scholar
  19. 19.
    Buchwald H, Estok R, Fahrbach K, et al. Trends in mortality in bariatric surgery: a systematic review and meta-analysis. Surgery 2007;142:621–32.CrossRefGoogle Scholar
  20. 20.
    Murr MM, Martin T, Torrella T, et al. A state-wide review of contemporary outcomes of gastric bypass in Florida: does provider volume impact outcomes? Ann Surg 2007;245:699–706.CrossRefGoogle Scholar
  21. 21.
    Flum DR, Dellinger EP. Impact of gastric bypass operations on survival: a population based analysis. J Am Coll Surg 2004;199:543–51.CrossRefGoogle Scholar
  22. 22.
    Latarjet A. Section des rameaux gastrique du vague. La Presse Med 1921;41:409.Google Scholar
  23. 23.
    McCrea ED. The abdominal distribution of the vagus. J Anat (London) 1924;59:18–40.Google Scholar
  24. 24.
    Ando S, Tsuji H. Surgical technique of vagus nerve-preserving gastrectomy with D2 lymphadenectomy for gastric cancer. ANZ J Surg 2008;78:172–6.CrossRefGoogle Scholar
  25. 25.
    Skandalakis LJ, Donahue PE, Skandalakis JE. The vagus nerve and its vagaries. Surg Clin North Α 1993;73:769–84.CrossRefGoogle Scholar
  26. 26.
    Moran TH, Kinzig KP. Gastrointestinal satiety signals II. Cholecystokinin. Am J Physiol Gastrointest Liver Physiol 2004;286:G183–8.CrossRefGoogle Scholar
  27. 27.
    Smith GP. The direct and indirect controls of meal size. Neurosci Biobehav Rev 1996;20:41–6.CrossRefGoogle Scholar
  28. 28.
    Powel TL, Chi MM, Schier LA, et al. Obesity: should treatment target visceral afferents? Physiol Behav 2005;86:698–708.CrossRefGoogle Scholar
  29. 29.
    McMahon MJ, Johnston D, Hill GL, et al. Treatment of severe side effects after vagotomy and gastroenterostomy by closure of gastroenterostomy without pyloroplasty. Br Med J 1979;1:7–8.CrossRefGoogle Scholar
  30. 30.
    Clements RH, Gonzalez QH, Long CI, et al. Hormonal changes after Roux-en Y gastric bypass for morbid obesity and the control of type-II diabetes mellitus. Am Surg 2004;70(1):1–4. Jan.PubMedGoogle Scholar
  31. 31.
    Rubino F, Gagner M, Gentileschi P, et al. The early effect of the Roux-en-Y gastric bypass on hormones involved in body weight regulation and glucose metabolism. Ann Surg 2004;240(2):236–42. Aug.CrossRefGoogle Scholar
  32. 32.
    Borg CM, le Roux CW, Ghatei MA, et al. Progressive rise in gut hormone levels after Roux-en-Y gastric bypass suggests gut adaptation and explains altered satiety. Br J Surg 2006;93(2):210–5. Feb.CrossRefGoogle Scholar
  33. 33.
    Karamanakos SN, Vagenas K, Kalfarentzos F, et al. Weight loss, appetite suppression, and changes in fasting and postprandial ghrelin and peptide-YY levels after Roux-en-Y gastric bypass and sleeve gastrectomy: a prospective, double blind study. Ann Surg 2008;247(3):401–7. Mar.CrossRefGoogle Scholar
  34. 34.
    le Roux CW, Welbourn R, Werling M, et al. Gut hormones as mediators of appetite and weight loss after Roux-en-Y gastric bypass. Ann Surg 2007;246(5):780–5. Nov.CrossRefGoogle Scholar
  35. 35.
    Sundbom M, Holdstock C, Engström BE, et al. Early changes in ghrelin following Roux-en-Y gastric bypass: influence of vagal nerve functionality? Obes Surg 2007;17(3):304–10. Mar.CrossRefGoogle Scholar

Copyright information

© Springer Science + Business Media, LLC 2008

Authors and Affiliations

  • A. Perathoner
    • 1
  • H. Weiss
    • 1
  • W. Santner
    • 2
  • G. Brandacher
    • 1
  • E. Laimer
    • 1
  • E. Höller
    • 1
  • F. Aigner
    • 1
  • A. Klaus
    • 1
    Email author
  1. 1.Center of Operative Medicine, Department of Visceral, Transplant and Thoracic SurgeryMedical University InnsbruckInnsbruckAustria
  2. 2.Department of RadiologyMedical University InnsbruckInnsbruckAustria

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