Revised sleeve gastrectomy: another option for weight loss failure after sleeve gastrectomy

Introduction

Laparoscopic sleeve gastrectomy (LSG) is becoming a very common bariatric procedure, based on several advantages it carries over more complex bariatric procedures such as gastric bypass or duodenal switch (DS), and a better quality of life over gastric banding. However, in the long-term follow-up, weight loss failure and intractable severe reflux after primary LSG can necessitate further surgical interventions, and revisional sleeve gastrectomy (ReSG) can represent an option to correct these.

Methods

From October 2008 to June 2013, 36 patients underwent an ReSG for progressive weight regain, insufficient weight, or severe gastroesophageal reflux in ‘La Casamance’ Private Hospital. All patients with weight loss failure after primary LSG underwent radiological evaluation. If Gastrografin swallow showed a huge unresected fundus or an upper gastric pouch dilatation, or if the computed tomography (CT) scan volumetry revealed a gastric tube superior to 250 cc, ReSG was proposed.

Results

Thirty-six patients (34 women, two men; mean age 41.3 years) with a body mass index (BMI) of 39.9 underwent ReSG. Thirteen patients (36.1 %) had their original LSG surgery performed at another hospital and were referred to us for weight loss failure. Twenty-four patients (66.6 %) out of 36 had a history of gastric banding with weight loss failure. Thirteen patients (36.1 %) were super-obese (BMI > 50) before primary LSG. The LSG was realized for patients with morbid obesity with a mean BMI of 47.1 (range 35.4–77.9). The mean interval time from the primary LSG to ReSG was 34.5 months (range 9–67 months). The indication for ReSG was insufficient weight loss for 19 patients (52.8 %), weight regain for 15 patients (41.7 %), and 2 patients underwent ReSG for invalidating gastroesophageal reflux disease. In 24 cases the Gastrografin swallow results were interpreted as primary dilatation, and in the remaining 12 cases results were interpreted as secondary dilatation. The CT scan volumetry was realized in 21 cases, and it has revealed a mean gastric volume of 387.8 cc (range 275–555 cc). All 36 cases were completed by laparoscopy with no intraoperative incidents. The mean operative time was 43 min (range 29–70 min), and the mean hospital stay was 3.9 days (range 3–16 days). One perigastric hematoma was recorded. The mean BMI decreased to 29.2 (range 20.24–37.5); the mean percentage of excess weight loss was 58.5 % (±25.3) (p < 0.0004) for a mean follow-up of 20 months (range 6–56 months).

Conclusions

The ReSG may be a valid option for failure of primary LSG for both primary or secondary dilatation. Long-term results of ReSG are awaited to prove efficiency. Further prospective clinical trials are required to compare the outcomes of ReSG with those of Roux en Y Gastric Bypass or DS for weight loss failure after LSG.     

Laparoscopic sleeve gastrectomy for morbid obesity

The epidemic of obesity in the United States is a major public health issue and more than a third of adults are now considered obese (body mass index ≥ 30 kg/m²). Surgery for morbid obesity, bariatric surgery, is the most durable treatment for this disease and about 140,000 cases are performed annually. Laparoscopic sleeve gastrectomy (LSG) has been advocated as the first of a 2-stage procedure for the high-risk, super-obese patient. More recently, LSG has been studied as a single-stage procedure for weight loss in the morbidly obese. LSG has been shown in initial studies to produce excellent excess weight loss comparable with laparoscopic Roux-en-Y gastric bypass in many series with a very low incidence of major complications and death. We describe our technique for LSG.     

Sleeve Gastrectomy as Sole and Definitive Bariatric Procedure: 5<Emphasis Type="Bold">-</Emphasis>Year Results for Weight Loss and Ghrelin

Background  

Due to excellent efficacy for weight loss in the short-term follow-up, sleeve gastrectomy (SG) has gained enormous popularity as bariatric procedure, not only as first step in high-risk or super-obese patients but mainly as a sole and definitive operation in morbidly obese. In contrast to a large number of short and intermediate-term results, no series of SG with a follow-up of 5 years or more has been published so far.     

Analysis of the results of sleeve gastrectomy for morbid obesity and the role of ghrelin

To evaluate the effectiveness of laparoscopic sleeve gastrectomy (LSG), a relatively new bariatric surgical procedure associated with duodenal switch (DS), we analyzed the findings of ten published studies on LSG. No relationship was found between the excess weight loss and the size of the bougie or the follow-up period. The amount of gastric fundus removed may be an important consideration because most ghrelin-producing cells are in the fundus; however, there is insufficient evidence that lowered ghrelin is the sole reason for the resulting weight loss after this procedure. Laparoscopic sleeve gastrectomy is still considered experimental by many, but the initial results are promising, with one study even suggesting long-term results comparable with those of other bariatric procedures. Ghrelin may play a role in the weight loss associated with LSG, but is unlikely to be the sole reason for its success.     

Feasibility of Laparoscopic Sleeve Gastrectomy as a Revision Procedure for Prior Laparoscopic Gastric Banding

Background: Laparoscopic sleeve gastrectomy (LSG), initially described by Gagner's group as the first stage of the laparoscopic duodenal switch in super-obese patients, is now gaining wide diffusion among bariatric surgeons as a new restrictive operation. Methods: From January 2005 to January 2006, 8 obese patients with BMI 37-74 kg/m² underwent LSG for conversion from a prior complicated or failed laparoscopic adjustable gastric banding (LAGB). Three patients had severe symptomatic esophageal dilation, while 5 patients had unsuccessful weight loss with poor "band compliance". After de-banding, LSG was calibrated upon a 34-Fr gastric bougie, and blue and green linear staplers were used. The staple-line was buttressed by placing a sero-serosal running suture in all but one patient, and methylene blue dye was used to test for leaks. All the patients underwent upper GI series with water-soluble contrast medium 2 days after the surgery. Results: The average operating-time for LSG was 90 minutes (range 60-120 min). The average hospital stay was 4 days (range 3-7). There were no perioperative complications, no conversion, and no mortality. No intraoperative or postoperative blood transfusions were required. Conclusions: LSG proved to be feasible and safe after LAGB. Longer follow-up and larger series are needed to assess weight loss results.     

Re-Sleeve Gastrectomy

Background: Laparoscopic sleeve gastrectomy (LSG) started as the restrictive part of the more complex laparoscopic duodenal switch (LDS) operation. There is no long-term experience with the isolated LSG. The main concern about the isolated LSG is the possibility of dilatation of the gastric pouch, long-term loss of restrictive function and weight regain. Laparoscopic re-sleeve gastrectomy (LRSG) has been used sparingly, but it also may become a possibility if more patients have the isolated LSG. Methods: 2 patients with BMI 58 and 65 respectively, underwent LSG as the first stage of the LDS. Later, when the patients regained some weight and their gastric pouch was found to be too large, the LRSG/DS was done. Results: The patient with BMI 58 had an initial drop to BMI 34 and regained weight to BMI 46, but after the LRSG/DS her BMI is 36 at 4 months. The BMI patient with BMI 65 had a drop to BMI 42, and after the LRSG/DS his BMI is 33 at 3 months later. Conclusion: LRSG may become necessary after gastric tube dilatation or insufficient original gastric volume reduction. LRSG is feasible, available and easy to perform when the resulting gastric pouch is too large or dilates after the original LSG.     

Sleeve Gastrectomy as a Stand-alone Bariatric Operation for Severe,Morbid, and Super Obesity

Background:

The laparoscopic sleeve gastrectomy (LSG) is emerging as an effective bariatric operation and is especially attractive in high-risk populations. In this study we examine the efficacy of LSG as a stand-alone operation in the veteran population.

Methods:

This is a retrospective review of consecutive patients who underwent LSG as a stand-alone procedure at the Palo Alto Veterans Affairs medical center with a minimum 12-month follow-up.

Results:

Of 205 patients undergoing bariatric surgery, 71 patients had a sleeve gastrectomy, 40 of whom had the operation performed at least 12 months previously. Thirty-six (90%) were available for 1-year follow-up, with a mean follow-up duration of 22 months (range: 12–42), a mean body mass index of 48.3 kg/m², and an 83% male population. Mean percent excess weight loss was 61% at an average of 22 months, with no significant difference between severely obese, morbidly obese, and super obese cohorts. Diabetes remission was seen in 56% of patients, hypertension remission in 51.6%, and obstructive sleep apnea remission in 46.4%, and gastroesophageal reflux disease improved or did not change in 83%. Medication use significantly decreased after surgery.

Conclusion:

LSG is safe and effective as a stand-alone bariatric operation in the high-risk veteran population. It is effective in severely obese, morbidly obese, and super obese patients. LSG induces remission or improvement in comorbidities of nearly all patients, translating to a decrease in medication use.     

Mid-term Results of Laparoscopic Sleeve Gastrectomy and Roux-en-Y Gastric Bypass in Adolescent Patients

The prevalence and severity of obesity in children and adolescents has been increasing in recent years at an unprecedented rate. Morbidly obese children will almost certainly develop severe comorbidities as they progress to adulthood, and bariatric surgery may provide the only alternative for achieving a healthy weight. The aim of this study was to assess the long-term outcomes and safety of laparoscopic sleeve gastrectomy (LSG) and Roux-en-Y gastric bypass (RYGB) as new treatment modalities for morbidly obese adolescents. We conducted a retrospective review of a prospectively collected database of all adolescent patients who underwent LSG and RYGB under IRB protocol at the Bariatric and Metabolic Institute in Cleveland Clinic Florida between 2002 and 2011. Patients were also contacted by phone, adhering to HIPAA regulations, and were asked to answer a survey. Eighteen adolescents had a bariatric procedure performed at this institution. The mean age was 17.5 years, the average weight was 293.1 lbs, and the average BMI was 47.2 kg/m². The mean follow-up period consisted of 55.2 months. The postoperative weight at 55 months follow-up was 188.4 lbs and average BMI was 30.1 kg/m². Fifteen of the patients were available for follow-up. Thirteen out of 16 (81 %) comorbidities in patients available for follow-up were in remission following rapid weight loss. The long-term follow-up and perioperative morbidity shown in this study suggest that LSG and LRYGB appear to be safe and effective operations in morbidly obese adolescents.     

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??Status of laparoscopic sleeve gastrectomy in bariatric surgery ZHU Jiang-fan??ZHOU Xiao-gang. Department of Diabetic and bariatric Surgery??East Hospital??Tongji University School of Medicine??Shanghai 200120??China
Corresponding author??ZHU Jiang-fan??E-mail??zhujiangfan@hotmail.com
Abstract Laparoscopic sleeve gastrectomy (LSG) is one of the major approaches for patients with morbid obesity and metabolic disorders. At first??the procedure was originally developed as a first-stage surgery to reduce surgical risk in super-obese patients??which then is considered as a definite procedure for its dramatic weight loss and metabolic improvement. LSG is as effective as laparoscopic Roux-en-Y gastric bypass in terms of weight loss and improvement of metabolic disorders. LSG has now been widely accepted for bariatric surgery in the world.     

Outcome of Portal Injuries Following Bariatric Operations

Background: Portal vein thrombosis is rare following Roux-en-Y gastric bypass (RYGBP). Its natural history is dependent on the etiology of the thrombosis. Iatrogenic injuries at bariatric operations resulting in portal vein thrombosis are lethal complications typically necessitating a liver transplant, whereas postoperative portal vein thrombosis without an injury to the portal vein has a benign course. There are currently no data on management or prognostic factors of portal vein thrombosis after bariatric operations. Methods: 3 patients referred for liver transplantation secondary to portal vein injury following bariatric surgery between 2000 and 2003 are presented. Results: 2 super-obese (BMI ≥50 kg/m²) and 1 morbidly obese (BMI 44 kg/m²) patients sustained portal vein injuries during bariatric surgery (RYGBP 2, VBG 1) by experienced bariatric surgeons. In each case, the portal injury was identified and repaired. Thrombosis followed reconstruction in all 3 patients. All 3 underwent emergency liver transplantation, but died of sepsis and multi-organ failure following transplantation. Review of the literature found no cases of traumatic portal vein injuries following bariatric operations and 2 cases of postoperative portal vein thrombosis: 1 following LRYGBP (BMI 46) and one after a Lap-Band (BMI 41). Conclusion: Injury to the portal vein resulting from difficulty in discerning the anatomy of the intra-abdominal structures in the morbidly obese, is a lethal complication of bariatric surgery. Super-obese patients submitting to bariatic surgery should lose weight, undergo a two-stage bariatric procedure, or undergo laparoscopic RYGBP to minimize the risk of portal injury. Postoperative portal vein thrombosis has a benign course and can be managed conservatively.