Skip to main content
SpringerLink
Log in

Intraoperative Patterns of Gastric Microperfusion During Laparoscopic Roux-en-Y Gastric Bypass

  • Original Contributions
  • Published:
Obesity Surgery Aims and scope Submit manuscript

Abstract

Introduction

Visible light spectroscopy (VLS) represents a sensitive, non-invasive method to quantify tissue oxygen levels and detect hypoxemia. The aim of this study was to assess the microperfusion patterns of the gastric pouch during laparoscopic Roux-en-Y gastric bypass (LRYGB) using the VLS technique.

Methods

Twenty patients were enrolled. Tissue oxygenation (StO2%) measurements were performed at three different localizations of the gastric wall, prior and after the creation of the gastric pouch, and after the creation of the gastro-jejunostomy.

Results

Prior to the creation of the gastric pouch, the lowest StO2% levels were observed at the level of the distal esophagus with a median StO2% of 43 (IQR 40.8–49.5). After the creation of the gastric pouch and after the creation of the gastro-jejunostomy, the lowest StO2% levels were recorded at the level of the His angle with median values of 29% (IQR 20–38.5) and 34.5% (IQR 19–39), respectively. The highest mean StO2 reduction was recorded at the level of the His angle after the creation of the gastric pouch, and it was 18.3% (SD ± 18.1%, p < 0.001). A reduction of StO2% was recorded at all localizations after the formation of the gastro-jejunostomy compared to the beginning of the operation, but the mean differences of the StO2% levels were statistically significant only at the resection line of the pouch and at the His angle (p = 0.044 and p < 0.001, respectively).

Conclusion

Gastric pouch demonstrates reduction of StO2% during LRYGB. VLS is a useful technique to assess microperfusion patterns of the stomach during LRYGB.

Graphical abstract

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7

Similar content being viewed by others

References

  1. Welbourn R, Hollyman M, Kinsman R, et al. Bariatric surgery worldwide: baseline demographic description and one-year outcomes from the fourth IFSO global registry report 2018. Obes Surg. 2019;29(3):782–95. https://doi.org/10.1007/s11695-018-3593-1.

    Article  PubMed  Google Scholar 

  2. Wang MC, Guo XH, Zhang YW, et al. Laparoscopic Roux-en-Y gastric bypass versus sleeve gastrectomy for obese patients with Type 2 diabetes: a meta-analysis of randomized controlled trials. Am Surg. 2015;81(2):166–71. https://doi.org/10.1177/000313481508100229.

    Article  PubMed  Google Scholar 

  3. Peterli R, Wolnerhanssen BK, Peters T, et al. Effect of laparoscopic sleeve gastrectomy vs laparoscopic roux-en-y gastric bypass onweight loss in patients with morbid obesity the sm-boss randomized clinical trial. JAMA - J Am Med Assoc. 2018;319(3):255–65. https://doi.org/10.1001/jama.2017.20897.

    Article  Google Scholar 

  4. Vidarsson B, Sundbom M, Edholm D. Incidence and treatment of leak at the gastrojejunostomy in Roux-en-Y gastric bypass: a cohort study of 40,844 patients. Surg Obes Relat Dis. 2019;15(7):1075–9. https://doi.org/10.1016/j.soard.2019.04.033.

    Article  PubMed  Google Scholar 

  5. Smith MD, Adeniji A, Wahed AS, et al. Technical factors associated with anastomotic leak after Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2015;11(2):313–20. https://doi.org/10.1016/j.soard.2014.05.036.

    Article  PubMed  Google Scholar 

  6. Thompson SK, Chang EY, Jobe BA. Clinical review: healing in gastrointestinal anastomoses, part I. Microsurgery. 2006;26(3):131–6. https://doi.org/10.1002/micr.20197.

    Article  PubMed  Google Scholar 

  7. Sverdén E, Mattsson F, Sondén A, et al. Risk factors for marginal ulcer after gastric bypass surgery for obesity: a population-based cohort study. Ann Surg. 2016;263(4):733–7. https://doi.org/10.1097/SLA.0000000000001300.

    Article  PubMed  Google Scholar 

  8. El-Hayek K, Timratana P, Shimizu H, et al. Marginal ulcer after Roux-en-Y gastric bypass: what have we really learned? Surg Endosc. 2012;26(10):2789–96. https://doi.org/10.1007/s00464-012-2280-x.

    Article  CAS  PubMed  Google Scholar 

  9. Wilson JA, Romagnuolo J, Byrne TK, et al. Predictors of endoscopic findings after Roux-en-Y gastric bypass. Am J Gastroenterol. 2006;101(10):2194–9. https://doi.org/10.1111/j.1572-0241.2006.00770.x.

    Article  PubMed  Google Scholar 

  10. Benaron DA, Parachikov IH, Friedland S, et al. Continuous, noninvasive, and localized microvascular tissue oximetry using visible light spectroscopy. Anesthesiology. 2004;25(6):1469–75. https://doi.org/10.1097/00000542-200406000-00019.

    Article  Google Scholar 

  11. Karliczek A, Benaron DA, Baas PC, et al. Intraoperative assessment of microperfusion with visible light spectroscopy for prediction of anastomotic leakage in colorectal anastomoses. Colorectal Dis. 2010;12(10):1018–25. https://doi.org/10.1111/j.1463-1318.2009.01944.x.

    Article  CAS  PubMed  Google Scholar 

  12. Karliczek A, Benaron DA, Baas PC, et al. Intraoperative assessment of microperfusion with visible light spectroscopy in esophageal and colorectal anastomoses. Eur Surg Res. 2008;41(3):303–11. https://doi.org/10.1159/000155880.

    Article  CAS  PubMed  Google Scholar 

  13. Delko T, Hoffmann H, Kraljevic M, et al. Intraoperative Patterns of gastric microperfusion during laparoscopic sleeve gastrectomy. Obes Surg. 2017;27(4):926–32. https://doi.org/10.1007/s11695-016-2386-7.

    Article  PubMed  Google Scholar 

  14. Saber AA, Azar N, Dekal M, et al. Computed tomographic scan mapping of gastric wall perfusion and clinical implications. Am J Surg. 2015;209(6):999–1006. https://doi.org/10.1016/j.amjsurg.2014.05.023.

    Article  PubMed  Google Scholar 

  15. Prudius V, Procházka V, Pavlovský Z, et al. Vascular anatomy of the stomach related to resection procedures strategy. Surg Radiol Anat. 2017;39(4):433–40. https://doi.org/10.1007/s00276-016-1746-2.

    Article  CAS  PubMed  Google Scholar 

  16. Varban OA, Cassidy RB, Sheetz KH, et al. Technique or technology? Evaluating leaks after gastric bypass. Surg Obes Relat Dis. 2016;12(2):264–72. https://doi.org/10.1016/j.soard.2015.07.013.

    Article  PubMed  Google Scholar 

  17. Acquafresca PA, Palermo M, Rogula T, et al. Early surgical complications after gastric by-pass: a literature review. Arq Bras Cir Dig. 2015;28(1):74–80. https://doi.org/10.1590/S0102-67202015000100019.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Fernandez AZ, DeMaria EJ, Tichansky DS, et al. Experience with over 3,000 open and laparoscopic bariatric procedures: multivariate analysis of factors related to leak and resultant mortality. Surg Endosc Other Interv Tech. 2004;18(2):193–7. https://doi.org/10.1007/s00464-003-8926-y.

    Article  Google Scholar 

  19. Pędziwiatr M, Małczak P, Wierdak M, et al. Revisional gastric bypass is inferior to primary gastric bypass in terms of short-and long-term outcomes—Systematic review and meta-analysis. Obes Surg. 2018;28(7):2083–91. https://doi.org/10.1007/s11695-018-3300-2.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Benois M, Sebastianelli L, Morisot A, et al. Revisional but not conversional gastric bypass surgery increases the risk of leaks: review of 176 redo out of 932 consecutive cases. Obes Surg. 2018;28(9):2903–11. https://doi.org/10.1007/s11695-018-3311-z.

    Article  PubMed  Google Scholar 

  21. Iannelli A, Schneck A-S, Hébuterne X, et al. Gastric pouch resizing for Roux-en-Y gastric bypass failure in patients with a dilated pouch. Surg Obes Relat Dis. 2013;9(2):260–7. https://doi.org/10.1016/j.soard.2012.05.003.

    Article  PubMed  Google Scholar 

  22. Borbély Y, Winkler C, Kröll D, et al. Pouch Reshaping for significant weight regain after Roux-en-y gastric bypass. Obes Surg. 2017;27(2):439–44. https://doi.org/10.1007/s11695-016-2329-3.

    Article  PubMed  Google Scholar 

  23. Shikora SA, Mahoney CB. Clinical benefit of gastric staple line reinforcement (SLR) in gastrointestinal surgery: a meta-analysis. Obes Surg. 2015;25(7):1133–41. https://doi.org/10.1007/s11695-015-1703-x.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Coblijn UK, Lagarde SM, de Castro SMM, et al. Symptomatic marginal ulcer disease after Roux-en-Y gastric bypass: incidence, risk factors and management. Obes Surg. 2015;25(5):805–11. https://doi.org/10.1007/s11695-014-1482-9.

    Article  PubMed  Google Scholar 

  25. Edholm D, Ottosson J, Sundbom M. Importance of pouch size in laparoscopic Roux-en-Y gastric bypass: a cohort study of 14,168 patients. Surg Endosc. 2016;30(5):2011–5. https://doi.org/10.1007/s00464-015-4432-2.

    Article  PubMed  Google Scholar 

  26. Dittrich L, Schwenninger MV, Dittrich K, et al. Marginal ulcers after laparoscopic Roux-en-Y gastric bypass: analysis of the amount of daily and lifetime smoking on postoperative risk. Surg Obes Relat Dis. 2020;16(3):389–96. https://doi.org/10.1016/j.soard.2019.11.022.

    Article  PubMed  Google Scholar 

  27. Francis N, Dort J, Cho E, et al. SAGES and EAES recommendations for minimally invasive surgery during COVID-19 pandemic. Surg Endosc. 2020. https://doi.org/10.1007/s00464-020-07565-w.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Spaniolas K, Yang J, Crowley S, et al. Association of long-term anastomotic ulceration after Roux-en-Y gastric bypass with tobacco smoking. JAMA Surg. 2018;153(9):862–4. https://doi.org/10.1001/jamasurg.2018.1616.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Süsstrunk J, Wartmann L, Mattiello D, et al. Incidence and prognostic factors for the development of symptomatic and asymptomatic marginal ulcers after Roux-en-Y gastric bypass procedures. Obes Surg. 2021;31(7):3005–14. https://doi.org/10.1007/s11695-021-05363-4.

    Article  PubMed  Google Scholar 

  30. Chahine E, Kassir R, Dirani M, et al. Surgical management of gastrogastric fistula after Roux-en-Y gastric bypass: 10-year experience. Obes Surg. 2018;28(4):939–44. https://doi.org/10.1007/s11695-017-2949-2.

    Article  PubMed  Google Scholar 

  31. Pauli EM, Beshir H, Mathew A. Gastrogastric fistulae following gastric bypass surgery—clinical recognition and treatment. Curr Gastroenterol Rep. 2014;16(9):1–8. https://doi.org/10.1007/s11894-014-0405-1.

    Article  Google Scholar 

  32. Iossa A, Abdelgawad M, Watkins BM, et al. Leaks after laparoscopic sleeve gastrectomy: overview of pathogenesis and risk factors. Langenbeck’s Arch Surg. 2016;401(6):757–66. https://doi.org/10.1007/s00423-016-1464-6.

    Article  Google Scholar 

Download references

Funding

The study was funded with grants from “Stiftung für chirurgische Forschung und Spitalmanagement” and grants from “Freiwillige Akademische Gesellschaft Basel.” Ioannis I. Lazaridis reports grants from Department of Surgery, University Hospital Basel, from Freiwillige Akademische Gesellschaft Basel, from Nora van Meeuwen- Häfliger Foundation, outside the submitted work. Romano Schneider reports grants from University of Basel, grants from Department of Surgery, University Hospital Basel, grants from SFCS, grants from Freiwillige Akademische Gesellschaft Basel and grants from Gebauer Stiftung, outside the submitted work. Marko Kraljević reports grants from Berrie Scholar in Diabetes Research, outside the submitted work. Jennifer M Klasen reports grants from Department of Surgery, University Hospital Basel and from Group of Educational Affairs (WGEA), honoraria from BPER, Centre for Faculty Development and CERI, Centre for Education Research & Innovation, outside the submitted work.

Author information

Author notes

  1. Ioannis I. Lazaridis and Romano Schneider contributed equally to this work and share first authorship

  2. Jennifer M Klasen and Tarik Delko contributed equally and share last authorship

Authors and Affiliations

  1. Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, 4002, Basel, Switzerland

    Ioannis I. Lazaridis, Romano Schneider, Marko Kraljević, Jennifer M Klasen & Tarik Delko

  2. Medical Faculty, University of Basel, 4056, Basel, Switzerland

    Roman Stocker

Authors
  1. Ioannis I. Lazaridis
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Romano Schneider
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Roman Stocker
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Marko Kraljević
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Jennifer M Klasen
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Tarik Delko
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Tarik Delko.

Ethics declarations

Ethics Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/ or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.

Conflict of Interest

The authors declare no competing interest.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Key Points

• During LRYGB, real-time tissue oxygenation measurements using VLS showed a significant reduction of tissue oxygenation at the ventral side of the staple line of the gastric pouch and at the level of the His angle.

• VLS during LRYGB is a safe and technically feasible procedure, which does not cause disturbance of the routine surgical workflow.

• Localized impairment of pouch microperfusion may be the pathophysiologic precursor of complications, such as anastomotic leaks, staple line leaks, gastro-gastric fistulas, and anastomotic ulcers.

Rights and permissions

Springer Nature or its licensor holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Lazaridis, I.I., Schneider, R., Stocker, R. et al. Intraoperative Patterns of Gastric Microperfusion During Laparoscopic Roux-en-Y Gastric Bypass. OBES SURG 32, 4047–4056 (2022). https://doi.org/10.1007/s11695-022-06318-z

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11695-022-06318-z

Keywords

Search

Navigation