Laparoscopic Sleeve Gastrectomy: A Multi-purpose Bariatric Operation

Background: The use of the laparoscopic sleeve gastrectomy (LSG), a restrictive operation, in different settings, is presented. Methods: 31 patients underwent LSG in the following groups: 1) 7 patients with very high BMI as a first stage of the duodenal switch (DS); 2) 7 morbidly obese patients with severe medical conditions; 3) 16 obese patients with lower BMI (35-43); and 4) 1 patient converted from a prior gastric banding. Results: 1 patient with BMI 74 died, a 3.2% mortality. The percentage of excess BMI loss (%EBMIL) in group 1 above was 63.1% from 4-27 months. The %EBMIL of the cirrhotics in group 2 was 76.0% (69-100%). The %EBMIL in group 3 patients was 68.5% (58.3-123%) at 3-27 months. The %EBMIL of the group 4 patient is 13% because she had previously lost almost all of her EBMI. Conclusion: LSG may become the ideal operation for staging in patients with BMI >55, for treating morbidly obese patients with severe medical conditions, as an excellent alternative to adjustable bands in lower BMI patients, or for conversion of gastric banding patients.     

Laparoscopic Sleeve Gastrectomy as a Single-Stage Bariatric Procedure

Background  

Laparoscopic sleeve gastrectomy is increasingly being used as a stand-alone procedure in bariatric surgery, with medium-term follow-up data now emerging. We present our early experience in patients with a mean body mass index (BMI) in the super-obese range.     

Revisional Bariatric Surgery Following Failed Primary Laparoscopic Sleeve Gastrectomy: A Systematic Review

Revisional bariatric surgery following laparoscopic sleeve gastrectomy (LSG) failure presents a clinical challenge for the bariatric surgeon. Limited evidence exists in selecting the appropriate revisional operation: laparoscopic gastric bypass (LGB), laparoscopic re-sleeve gastrectomy (LRSG), or other surgical intervention (OSI), to address weight regain. We systematically reviewed the literature to assess the efficacy of existing revisional surgery. A comprehensive search of electronic databases (e.g., Medline, Embase, Scopus, Web of Science, and the Cochrane Library) was completed. All randomized controlled trials, non-randomized comparison study, and case series were included. Eleven primary studies (218 patients) were identified and included in the systematic review. Studies were grouped into three main categories: LGB, LRSG, and OSI. Preoperative body mass index (BMI) was 41.9 kg/m² (LGB), 38.5 kg/m² (LRSG), and 44.4 kg/m² (OSI). After conversion to LGB, BMI decreased to 33.7 and 35.7 kg/m² at 12 and 24 months of follow-up, respectively. Excess weight loss (EWL) was 60 and 48 % over the same periods. After LRSG, BMI decreased to 30.4 and 35.3 kg/m² with corresponding EWL of 68 and 44 %, at 12 and 24 months, respectively. After OSI, BMI decreased to 27.3 kg/m² with an EWL of 75 % at 24-month follow-up but could not be analyzed due to incomplete data collection in primary studies. Both LGB and LRSG achieve effective weight loss following failed LSG. The less technically challenging nature of LRSG may be more widely applicable. Further research is required to elicit sustainability in long-term weight loss benefits.     

Medium-Term Results of Combined Laparoscopic Sleeve Gastrectomy and Modified Jejuno-Ileal Bypass in Bariatric Surgery

Background

The ideal bariatric operation achieves 70–100 % maintained excess weight loss, is simple with low operative risks, and maintains absorption of trace elements. Our aim was to find a bariatric procedure that achieves the above while avoiding drawbacks of current options.

Methods

A standard sleeve gastrectomy was combined with a modified jejuno-ileal bypass dividing the small bowel 75 cm distal to the duodeno-jejunal flexure, anastomosing it to the ileum 75 cm proximal to the ileocaecal valve. Operative and follow-up data were collected prospectively between December 2004 and January 2013.

Results

One hundred sixty-eight procedures were analysed (110 female, 58 male). Mean patient age was 43 years (IQR 37–47), and median preoperative body mass index (kg/m²) was 52 (IQR 49–59). All operations were completed laparoscopically. Excess weight loss was 78 % (IQR 70–83 %, 12 months, n?=?168), 79 % (IQR 70–85 %, 24 months), maintained at most recent follow-up with 77 % (IQR 68–84 %, n?=?168), and for 8 year follow-up alone 75 % (IQR 66–84 %, n?=?18). There was no operative mortality and 5.4 % morbidity. A 6.5 % of patients experienced transient vomiting. No symptoms of dumping or bacterial overgrowth were observed. All had normal liver enzymes. Hypocalcaemia (20.8 %) and zinc deficiency (25.6 %) resolved with oral supplementation. Type 2 diabetes mellitus resolved in 80.3 % and improved in the remainder of patients, hypertension resolved in 92.3 % and improved in the rest.

Conclusions

Whilst currently an investigative procedure, and within the studies limitations combined sleeve gastrectomy with modified jejuno-ileal bypass is safe and effective, and evades many problems associated with current bariatric operations whilst offering maintained excess weight loss.

     

腹腔镜袖状胃切除术

患者女性，30岁，BMI36.6，诊断代谢综合征。患者平卧"大"字位，头高左侧高30°，主刀右侧站位。距幽门2 cm开始紧贴胃壁游离胃大弯，充分游离胃底，显露左侧膈肌脚及食道左侧，经口置入36 F减重胃管，沿胃管距幽门4 cm开始进行袖状胃裁剪，根据胃壁厚度应用不同钉脚高度的切割闭合钉，连续全层缝合加固胃切缘，并将胃切缘复位固定于大网膜及胰腺背膜，经主操作孔取出切除的胃组织，清理腹腔，放置引流管，缝合戳卡孔。     

Nutritional Status Prior to Laparoscopic Sleeve Gastrectomy Surgery

Background

Two main causes for nutrient deficiencies following bariatric surgery (BS) are pre-operative deficiencies and favoring foods with high-energy density and poor micronutrient content. The aims of this study were to evaluate nutritional status and gender differences and the prevalence of nutritional deficiencies among candidates for laparoscopic sleeve gastrectomy (LSG) surgery.

Methods

A cross-sectional analysis of pre-surgery data collected as part of a randomized clinical trial on 100 morbidly obese patients with non-alcoholic fatty liver disease (NAFLD) admitted to LSG surgery at Assuta Medical Center between February 2014 and January 2015. Anthropometrics, food intake, and fasting blood tests were evaluated during the baseline visit.

Results

One-hundred patients completed the pre-operative measurements (60 % female) with a mean age of 41.9?±?9.8 years and a mean BMI of 42.3?±?4.7 kg/m². Pre-operatively, deficiencies for iron, ferritin, folic acid, vitamin B1, vitamin B12, vitamin D, and hemoglobin were 6, 1, 1, 6, 0, 22, and 6 %, respectively. Pre-surgery, mean energy, protein, fat, and carbohydrate intake were 2710.7?±?1275.7 kcal/day, 114.2?±?48.5, 110.6?±?54.5, and 321.6?±?176.1 gr/day, respectively. The intakes for iron, calcium, folic acid, vitamin B12, and vitamin B1 were below the Dietary Reference Intake (DRI) recommendations for 46, 48, 58, 14, and 34 % of the study population, respectively.

Conclusion

We found a low prevalence of nutritional deficiencies pre-operatively except for vitamin D. Most micronutrient intake did not reach the DRI recommendations, despite high-caloric and macronutrient intake indicating a poor dietary quality.

     

Previous Bariatric Surgery Increases Postoperative Morbidity after Sleeve Gastrectomy for Morbid Obesity

Objectives : Sleeve gastrectomy (SG) has been used as the first step of a staged malabsorptive procedure for high-risk patients. More recently SG was proposed as an stand alone procedure in the treatment of morbidly obese patients. The aim of this study is to analyze perioperative outcome of morbid obese patients after SG. Methods : 301 patients, 201 women and 100 men, undergoing SG were retrospectively analyzed. SG was performed by 17 surgeons all member of the Club Coelio.

The mean BMI was 44.7kg/m² (27.4–70.3 kg/m²). 34 patients (11.3%) of our series had SG as revisional surgery. These revisional procedures consisted of 32 conversions from gastric banding, 1 conversion from vertical gastroplasty (VBG) and 1 from transoral endoscopic gastroplasty. Among the 32 patients that had revisional SG after a gastric banding, 13 bands were removed at least 3 months before the revisional SG and 19 bands were removed during the SG procedure. Endpoints were perioperative morbidity and mortality and potential risk factors for complications, mainly per or postoperative bleeding or leakage.

Results : Overall mortality was 0% and morbidity was 10.3%. Perioperative bleeding occurred in 10 patients (3.3%), leakage in 12 patients (4%) patients and stenosis in 3 patients (1%). The risk of leakage was significantly higher after revisional bariatric surgery and in case of gastric perforation during surgery(p = 0.0001). Previous gastric banding is also associated with a higher risk of postoperative bleeding (p = 0.0006).

Conclusions : SG can be safely performed but patients and surgeons must be aware of a higher risk of postoperative complications when SG is proposed as a revisional surgery.     

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.     

Readmission Following Laparoscopic Sleeve Gastrectomy

Methods:Data on 343 consecutive LSG operations performed from February 2010 to May 2014 by a single surgeon (PG) were analyzed. Patients readmitted within 30 d were compared to the remaining patients by using Student''s t test for continuous variables and the χ² test for categorical variables.Results:All LSGs were completed laparoscopically with no conversions to open procedures. There were no reoperations, leaks, perioperative hemorrhages, or mortalities. Twelve patients (3.5%) were readmitted; 1 was readmitted twice. There were no identified risk factors for readmission, including patient demographics, comorbidities, and perioperative factors. Notably, 7 (7%) readmissions occurred in the initial 100 patients and 5 (2%) in the remaining 243 patients (P = .04). Clinical pathways were modified after the initial 100 patients; routine contrast esophagograms were no longer performed, and a 1-day routine postoperative stay was adopted. Operative time also decreased from 94.2 ± 23.8 to 78.2 ± 20.0 min (P < .001).Conclusions:Readmission rates after LSG remain in a range similar to those described for other laparoscopic bariatric procedures. Larger prospective studies are needed to identify patterns of complications and readmissions in patients undergoing LSG that may differ from other bariatric procedures.     

Laparoscopic Sleeve Gastrectomy for Late Adolescent Population

Background

Morbid obesity prevalence is rapidly increasing among adolescents worldwide. Evidence is mounting that bariatric surgery is the only reliable method for substantial and sustainable weight loss; however, the debate continues with regard to the optimal surgical procedure for adolescents and to the age limit when bariatric surgery should be proposed.

Methods

A retrospective multicenter review included all late adolescent patients (<20 years old) who underwent sleeve gastrectomy from 2005 to 2012 in three French bariatric centers: Montpellier University Hospital, Casamance Private Hospital, and Noumea Regional Hospital. Collected data included age, sex, body mass index (BMI), intraoperative complications, length of hospital stay, operative morbidity, the need for reoperation, and percentage of excess weight loss (% EWL) at 6 months, 1 year, and 2 years postoperatively.

Results

A total of 61 adolescent patients have undergone sleeve gastrectomy. Of these, 42 were women and 19 were men. The mean preoperative weight was 132.8 kg (range 90–217 kg) with a BMI of 46.7 (range 35.5–68.7). Seventeen patients (27.9 %) were superobese (BMI?>?50), and seven patients (11.5 %) were supersuperobese (BMI?>?60). All the procedures were performed by laparoscopy with no intraoperative complications. The mean hospital stay was 4.6 days. Four major complications were recorded: one staple line leak, two hematomas, and one case of pneumonia. No mortality was recorded. The % EWL at 6 months, 1 year, and 2 years postoperatively was 48.1 % (±17.9 %), 66.7 % (±19.5 %), and 78.4 % (±16.8 %), respectively, for a follow-up of 93.4, 81.9, and 52.4 %, respectively. There were 18 patients (29.5 %) with identified comorbid conditions: 10 cases of sleep apnea, 7 cases of hypertension, and 1 case of type 2 diabetes, with a resolution rate of 77.8 %.

Conclusions

Laparoscopic sleeve gastrectomy may be advantageous for this age group, since it involves neither foreign body placement nor lifelong malabsorption. Laparoscopic sleeve gastrectomy represents an attractive bariatric procedure for adolescent patients, more efficient than gastric banding and with less morbidity compared to gastric bypass.     

Laparoscopic Sleeve Gastrectomy for Morbid Obesity in 3003 Patients: Results at a High-Volume Bariatric Center

Background

Laparoscopic sleeve gastrectomy (LSG) is gaining wide acceptance as a single surgical treatment for obesity. The reported morbidity and mortality rates are low. We herein report the results of LSG performed in a high-volume center by an experienced team.

Methods

Retrospective analysis of a prospectively maintained database of all bariatric surgery (BS) was performed between May 2006 and December 2014. Data inspected included operative time, length of hospital stay (LOS), comorbidity resolution, re-operation, percent excess weight loss (%EWL), and 30-day morbidity and mortality.

Results

In the study period, 3003 patients underwent BS (1901 (63 %) female). Mean age and body mass index (BMI) were 43 years (range 14–73) and 42.8 kg/m² (range 35–73), respectively. %EWL at 1 year was 72 % (n?=?937; 57 % follow-up rate). There was 1 perioperative mortality due to bleeding (0.03 %). Comorbidity improvement and resolution were 98 % for obstructive sleep apnea, 79 % for diabetes mellitus, 87 % for dyslipidemia, and 85 % for hypertension. Mean operative time and LOS were 50 min (range 32–94) and 2.2 days (range 1–38), respectively. Of the patients, 132 had complications (4.4 %), 25 leaks (0.83 %), 63 bleeding (2.1 %), 1 intra-abdominal abscesses (0.03 %), 3 sleeve strictures (0.1 %), 2 mesenteric vein thromboses (0.06 %), 10 trocar site hernias (0.3 %), and 78 symptomatic cholelithiasis (2.6 %). Re-operation was needed in 13 patients (0.43 %).

Conclusion

In a high-volume center with an experienced team, LSG can be performed with low morbidity and mortality.

     

Conversional Surgery: Single-Step Conversion of Laparoscopic Adjustable Gastric Band to Laparoscopic Sleeve Gastrectomy

Background

Although some patients attain good outcomes after adjustable gastric band (LAGB), a certain quantity have experienced complications and insufficient weight loss. The objective of this study is to assess the safety and outcome of laparoscopic sleeve gastrectomy (LSG) as a conversion surgery after a failed LAGB.

Methods

This is a retrospective analysis of 40 patients who received LSG as conversional surgery from 2009 to 2012 in Al Amiri Hospital, Kuwait. Data analyzed included percentage of excessive weight loss (EWL%), body mass index (BMI), and postoperative complications. Paired t test was utilized to evaluate total weight loss after both procedures.

Results

Among the 40 patients that underwent conversion surgery, the mean age was 36 years old, 34 (85 %) of which were females. Follow-up for LAGB was 1 to 11 years (median, 4.5 years) and 6 months to 3 years (median, 1 year) for LSG. Mean BMI before LAGB was 44 kg/m² (SD?=?7.2) and mean weight was 117.2 kg (SD?=?25.1). A percentage of 20 % achieved good outcomes and 7.5 % experienced complications and 60 % insufficient weight loss. Median EWL% achieved with LAGB was 11.5 %, and after LSG, a median EWL% of 56.9 % was recorded. After conversional surgery, a significant drop in BMI was noted with p value?Conclusions Laparoscopic conversion from LAGB to LSG may be considered as an alternative for patients with a failed LAGB procedure. However, a longer follow-up study is required to validate the results.     

Technical Controversies in Laparoscopic Sleeve Gastrectomy

Laparoscopic sleeve gastrectomy is a recently developed technique for treating morbid obesity. Since it is a simple procedure, many bariatric surgeons have adopted it in recent years with good results. However, there is still no standard procedure across different surgical teams. We will discuss the more controversial aspects of the surgical technique: the size of the bougie, the beginning of the distal section, the section shape at the gastroesophageal junction, the necessity and manner of reinforcing the staple line, and the routine use of intraoperative leak testing.     

Laparoscopic Total Gastrectomy with Roux-Y Esophagojejunostomy for Chronic Gastric Fistula After Laparoscopic Sleeve Gastrectomy

Laparoscopic sleeve gastrectomy is a restrictive operation with hormonal elements that is rapidly gaining popularity. The most feared complication of the procedure is a staple line leak. The treatment of staple line leakage depends on timing and clinical and anatomical considerations. If leakage persists and transforms into a chronic fistula, a definitive surgical procedure is required. In cases where the fistula originates close to the esophagogastric junction, the surgical possibilities are limited and one treatment option is total gastrectomy with esophagojejunal anastomosis. We report a case series of four patients with chronic fistulae, who failed conservative treatment and required total gastrectomy. Their average length of hospital stay was 8.7 days (range, 5–15 days), without conversions, leaks, or other complications. In experienced hands, total gastrectomy is feasible by laparoscopic techniques and should be performed soon after the fistula is established.     

Gastric Leak After Laparoscopic Sleeve Gastrectomy

Sleeve gastrectomy is a recently developed technique for treating morbid obesity. Since it is a simple procedure, the number of surgeons using it has grown in recent years. The patients who present fistulas after surgery often undergo a harrowing postoperative period as well as increased morbidity and mortality. Our aim was to assess the incidence, causes, diagnosis, management, and prevention of leaks after sleeve gastrectomy.