Critical analysis of the staged laparoscopic Roux-en-Y: a two-stage operation to diminish the size of the liver in super-obese patients.

We read the interesting paper Staged Laparoscopic Roux-en-Y: A Novel Two-Stage Bariatric Operation as an Alternative in the Super-obese with Massively Enlarged Liver, by the renowned Ninh T. Nguyen, with M. Longoria, D.V. Gelfand, A. Sabio, and S.E. Wilson.1 The enlarged liver is a major concern for the bariatric surgeon. The effort to create alternatives to operate on patients with this problem is very important. The technique described is a very intelligent idea, but the pioneers have to overcome the uncertainty with this new procedure. Some points in this article are controversial. This new technique is not a simple and easy operation; severe complications can occur in super-obese patients submitted to this procedure. The first stage of the procedure consists of three main steps: 1) gastric partition; 2) entero-anastomosis; 3) gastrojejunostomy (Figure 1). The latter stage of the procedure is similar to the biliopancreatic diversion with gastric preservation as performed by Domene in Brazil,2 differing in the length of the alimentary and biliopancreatic limbs. The second stage of the procedure consists of a sleeve gastrectomy (Figures 2A-C) performed 6 to 12 months after the first stage. These several steps make this operation as complex as many bariatric operations. The laparoscopic RYGBP in the super-obese is associated with higher morbidity and mortality as demonstrated by Artuso et al,3 and the two-stage procedure probably has the same outcome. The operated individual may develop several complications in any of the three steps, e.g. 1) acute gastric dilatation, 2) bleeding in the staple-line, 3) intra-abdominal bleeding, 4) gastrojejunostomy and jejunojenunostomy dehiscence, 5) gastrojejunostomy fistula, 6) intestinal obstruction. If this technique is compared to the sleeve gastrectomy, the latter has less complications and is a faster procedure. Surgical time is very important in the super-obese, preventing complications related to longer operations such as rhabdomyolysis.4 The authors perform the gastrojejunal anastomosis low on the lesser curvature, and in doing that, they create a longer gastric pouch. In the future, lengthening can defeat the weight loss from the non-banded gastric bypass, so that the suggested first stage should have a smaller pouch. Another problem in the superobese is the thickened mesocolon and its weight during creation of the retrocolic tunnel;3 this difficult task can be solved if the gastrojejunostomy is performed ante-colic ante-gastric. The authors note that “the primary limiting factor making laparoscopic gastric bypass challenging in the super-obese is the volume of the left lobe of the liver”. Many surgeons have good results with a diet with a minimum amount of carbohydrates for 1-2 months before operation which diminishes the thickened lobe of the liver. Even if the liver is unexpectedly large when one passes the laparoscope, the Correspondence