DeMaria E J, Schweitzer M A, Kellum J M, Meador J, Wolfe L, Sugerman H J
Department of Surgery, Center for Minimally Invasive Surgery, Medical College of Virginia Campus of Virginia Commonwealth University, MCV Box 980519, 1200 Broad Street, Richmond, VA 23298, USA.
Surg Endosc. 2002 Oct;16(10):1452-5. doi: 10.1007/s00464-001-8321-5. Epub 2002 Jun 14.
Hand-assisted laparoscopic Roux-en-Y gastric bypass (Hand-Lap GB) has been adopted by some surgeons to treat morbid obesity because it is easier to perform than the total laparoscopic procedure, but to date no study has compared the outcomes of patients undergoing the Hand-Lap GB to those obtained with the open procedure (Open GB). We hypothesized that patients undergoing Hand-Lap GB would lose a similar amount of weight when compared to Open GB patients, while experiencing no increase in complications, a shorter hospital stay, and lower overall costs of care, in part as a result of fewer incisional hernias requiring subsequent surgery.
Nonrandomized, prospective data were collected on all patients undergoing proximal GB via Hand-Lap or open approaches between May 1998 and July 1999. Our first 25 Hand-Lap GB procedures, performed in selected patients (with no extensive previous abdominal surgery) referred to two of us (E.J.D, M.A.S), were compared to all other (n = 62) concurrent open proximal GB performed by the group during this period of time in patients with body mass index (BMI) <50 kg/m2.
Preoperatively, Hand-Lap GB patients did not differ from Open GB patients in age (40 +/- 11 vs 43 +/- 11 years), gender (92% female vs 81% female), incidence or type of preoperative comorbid conditions, preoperative weight (282 +/- 33 vs 280 +/- 37 lb), or BMI (45.5 +/- 5.4 vs 44.1 +/- 3.3 kg/m2). (Data given as mean +/- standard deviation). Although length of hospital stay did not differ between groups (3.6 +/- 1.3 vs 4.2 +/- 4.6 days), total hospital costs were significantly higher for Hand-Lap GB ($14,725 +/- 3089 vs. $10,281 +/- 3687, p <0.01 ANOVA). One patient in the Open GB group developed an anastomotic leak from the gastrojejunostomy. Follow-up revealed that Hand-Lap GB patients had a similar risk of postoperative complications as the Open GB group, including marginal ulcer (16% vs 14.5%), stomal stenosis (24% vs 23%), and, most notably, incisional hernia (20% vs 27%). There were no major wound infections or deaths in either group. One patient in each group developed a postoperative small bowel obstruction. Loss of excess weight in Hand-Lap GB patients at 12 months postoperatively was 66 +/- 14% vs 77 +/- 14% in the Open GB group.
The Hand-Lap GB yielded good weight reduction in a population of morbidly obese patients, but at a higher cost for hospital care than Open GB. There was no decrease in the incidence of incisional hernias with the Hand-Lap GB procedure. Although Hand-Lap GB appears to be safe and effective, its failure to provide a decrease in hospital stay or risk of incisional hernia requiring subsequent surgical repair is significant. The primary role for the Hand-Lap GB procedure should therefore be to aid surgeons in developing skills to climb the steep learning curve for total laparoscopic gastric bypass, since Hand-Lap GB does not improve patient outcome and increases cost in comparison to the open GB procedure.
一些外科医生采用手辅助腹腔镜Roux-en-Y胃旁路术（Hand-Lap GB）治疗病态肥胖，因为它比全腹腔镜手术更容易实施，但迄今为止，尚无研究比较接受Hand-Lap GB手术的患者与接受开放手术（Open GB）的患者的治疗结果。我们推测，与Open GB患者相比，接受Hand-Lap GB手术的患者体重减轻量相似，同时并发症不增加，住院时间更短，总体护理成本更低，部分原因是需要后续手术的切口疝较少。
收集1998年5月至1999年7月期间所有通过Hand-Lap或开放手术方式接受近端GB手术的患者的非随机前瞻性数据。我们将最初在选定患者（既往无广泛腹部手术史）中进行的25例Hand-Lap GB手术（由我们两人（E.J.D，M.A.S）实施）与同期该组在体重指数（BMI）<50 kg/m²的患者中进行的所有其他（n = 62）同期开放近端GB手术进行比较。
术前，Hand-Lap GB患者与Open GB患者在年龄（40±11岁对43±11岁）、性别（女性92%对女性81%）、术前合并症的发生率或类型、术前体重（282±33磅对280±37磅）或BMI（45.5±5.4 kg/m²对44.1±3.3 kg/m²）方面无差异。（数据以均值±标准差表示）。尽管两组的住院时间无差异（3.6±1.3天对4.2±4.6天），但Hand-Lap GB的总住院费用显著更高（14,725±3089美元对10,281±3687美元，方差分析p<0.01）。Open GB组有1例患者发生胃空肠吻合口漏。随访显示，Hand-Lap GB患者术后并发症风险与Open GB组相似，包括边缘溃疡（16%对14.5%）、吻合口狭窄（24%对23%），最显著的是切口疝（20%对27%）。两组均无严重伤口感染或死亡病例。每组各有1例患者发生术后小肠梗阻。Hand-Lap GB患者术后12个月超重体重减轻率为66±14%，而Open GB组为77±14%。
Hand-Lap GB在病态肥胖患者群体中实现了良好的体重减轻，但住院护理成本高于Open GB。Hand-Lap GB手术并未降低切口疝的发生率。尽管Hand-Lap GB似乎安全有效，但其未能缩短住院时间或降低需要后续手术修复的切口疝风险，这一点很重要。因此，Hand-Lap GB手术的主要作用应该是帮助外科医生培养技能，以跨越全腹腔镜胃旁路术陡峭的学习曲线，因为与开放GB手术相比，Hand-Lap GB并未改善患者预后且增加了成本。
