Single-Incision Sleeve Gastrectomy Versus Conventional Laparoscopic Sleeve Gastrectomy—a Randomised Pilot Study

Background  

This is a prospective pilot study done to evaluate the feasibility and to assess the outcomes and complication rates of the single-incision sleeve gastrectomy versus the conventional five-port laparoscopic sleeve gastrectomy.     

Long-Term Outcomes of Laparoscopic Sleeve Gastrectomy—a Single-Center,Retrospective Study

Introduction

Sleeve gastrectomy (LSG) is one of the most popular bariatric procedures. We present our long-term results regarding weight loss, comorbidities, and gastric reflux disease.

Material and Methods

We identified patients who underwent LSG in our institution between 2006 and 2009. We revised the data, and the patients with outdated contact details were tracked with the national health insurance database and social media (facebook). Each of the identified patients was asked to complete an online or telephone survey covering, among others, their weight and comorbidities. On that basis, we calculated the percent total weight loss (%TWL) and percent excess weight loss (%EWL), along with changes in body mass index (ΔBMI). Satisfactory weight loss was set at >50% EWL (for BMI = 25 kg/m²). We evaluated type 2 diabetes (T2DM) and arterial hypertension (AHT) based on the pharmacological therapy. GERD presence was evaluated by the typical symptoms and/or proton pump inhibitor (PPI) therapy.

Results

One hundred twenty-seven patients underwent LSG between 2006 and 2009. One hundred twenty patients were qualified for this study. Follow-up data was available for 100 participants (47 female, 53 male). Median follow-up period reached 8.0 years (from 7.1 to 10.7). Median BMI upon qualification for LSG was 51.6 kg/m². Sixteen percent of patients required revisional surgery over the years (RS group), mainly because of insufficient weight loss (14 Roux-Y gastric bypass—LRYGB; one mini gastric bypass, one gastric banding). For the LSG (LSG group n = 84), the mean %EWL was 51.1% (±22.3), median %TWL was 23.5% (IQR 17.7–33.3%), and median ΔBMI was 12.1 kg/m² (IQR 8.2–17.2). Fifty percent (n = 42) of patients achieved the satisfactory %EWL of 50%. For RS group, the mean %EWL was 57.8% (±18.2%) and median %TWL reached 33% (IQR 27.7–37.9%). Sixty-two percent (n = 10) achieved the satisfactory weight loss. Fifty-nine percent of patients reported improvement in AHT therapy, 58% in T2DM. After LSG, 60% (n = 60) of patients reported recurring GERD symptoms and 44% were treated with proton pomp inhibitors (PPI). In 93% of these cases, GERD has developed de novo.

Conclusions

Isolated LSG provides fairly good effects in a long-term follow-up with mean %EWL at 51.1%. Sixteen percent of patients require additional surgery due to insufficient weight loss. More than half of the subjects observe improvement in AHT and T2DM. Over half of the patients complain of GERD symptoms, which in most of the cases is a de novo complaint.

     

Laparoscopic Sleeve Gastrectomy—Volume and Pressure Assessment

BACKGROUND: Aiming to clarify the mechanism of weight loss after the restrictive bariatric procedure of sleeve gastrectomy (LSG), the volumes and pressures of the stomach, of the removed part, and of the remaining sleeve were measured in 20 morbidly obese patients. METHODS: The technique used consisted of occlusion of the pylorus with a laparoscopic clamp and of the gastroesophageal junction with a special orogastric tube connected to a manometer. Instillation of methylene-blue-colored saline via the tube was continued until the intraluminal pressure increased sharply, or the inflated stomach reached 2,000 cc. After recording of measurements, LSG was performed. RESULTS: Mean volume of the entire stomach was 1,553 cc (600-2,000 cc) and that of the sleeve 129 cc (90-220 cc), i.e., 10% (4-17%) and that of the removed stomach was 795 cc (400-1,500 cc). The mean basal intragastric pressure of the whole stomach after insufflations of the abdominal cavity with CO(2) to 15 mmHg was 19 mmHg (11-26 mmHg); after occlusion and filling with saline it was 34 mmHg (21-45 mmHg). In the sleeved stomach, mean basal pressure was similar 18 mmHg (6-28 mmHg); when filled with saline, pressure rose to 43 mmHg (32-58 mmHg). The removed stomach had a mean pressure of 26 mmHg (12-47 mmHg). There were no postoperative complications and no mortality. CONCLUSIONS: The notably higher pressure in the sleeve, reflecting its markedly lesser distensibility compared to that of the whole stomach and of the removed fundus, indicates that this may be an important element in the mechanism of weight loss.     

Laparoscopic Sleeve Gastrectomy for High-Risk Patients: Weight Loss and Comorbidity Improvement—Short-Term Results

Background  

The obesity surgery mortality risk score (OS-MRS) is a five-point scoring system stratifying the risk of post-operative mortality. Patients with a body mass index (BMI) > 60 may also carry an increased risk of peri-operative complications. Laparoscopic sleeve gastrectomy (LSG) as an initial procedure could reduce weight and associated comorbidity allowing a safer, definitive second procedure. We investigated weight loss and risk reduction in patients having LSG as part of a planned two-stage definitive bariatric procedure.     

The True Incidence of Gastric GIST—a Study Based on Morbidly Obese Patients Undergoing Sleeve Gastrectomy

Background

Gastrointestinal stromal tumor (GIST) is a rare neoplasm of the alimentary tract. Previous reports described an incidence of 1 per 100,000. Laparoscopic sleeve gastrectomy (LSG) provides pathological specimens of the majority of the stomach. We examined the pathology from LSG and the incidence and location of GIST. The aim of this study was to study the incidence of asymptomatic GISTs found during LSG at our institution.

Methods

A search was conducted in a prospectively maintained bariatric registry. Data collected included the following: gender, age, body mass index (BMI), and concomitant hypertension or diabetes mellitus. Histopathology reports were reviewed for incidental GIST. We compared the patients with incidental GIST to the rest of the cohort.

Results

Pathology reports of 827 patients that underwent LSG between 2007 and 2014 were reviewed. Five patients had GIST in the resected stomach, an incidence of 0.6 %. The group of patients with GIST had lower BMI and older age compared to the remaining 822 patients. All tumors were located close to the lesser curvature.

Conclusions

The incidence of GIST found in this cohort is significantly higher than previously reported. This may be due to an association between these tumors and obesity or because asymptomatic GISTs are underdiagnosed in the general population. These tumors are particularly common in older patients and special attention must be given when performing LSG on this subpopulation. The stomach should be inspected thoroughly before resection. A tumor on the lesser curvature may necessitate changing the surgical plan or aborting the procedure.     

Laparoscopic Sleeve Gastrectomy — Influence of Sleeve Size and Resected Gastric Volume

Background Although the efficacy of laparoscopic sleeve gastrectomy (LSG) for morbidly obese patients with a BMI of < 50 kg/m², the incidence of weight gain by change of eating behaviors, and gastric dilatation following LSG have not been investigated thus far, LSG is becoming more common as a single-stage operation for the treatment morbid obesity. Methods This is a prospective study of the initial 120 patients who underwent isolated LSG. Initially, the LSG was performed without a calibration tube and resulted in high sleeve volumes (group 1: n = 25). In group 2 (n = 32), a calibration tube of 44 Fr and in group 3 (n = 63) a calibration tube of 32 Fr were used. The study group consists of 101 patients with high BMI who were scheduled for a two-step LBPD-DS, but rejected the second step after 1 year. Study endpoints include estimated sleeve volume, volume of removed stomach, operative time, complication rates, length of hospital stay, changes in co-morbidity, percentage of excess BMI loss (%EBL) and changes in BMI (kg/m²). Results All 3 groups were comparable regarding age, gender, and co-morbidities. There was no hospital mortality, but there was one case of late mortality (0.8%). 2 early leaks (1.7%) were seen. % excess BMI loss was significantly higher for patients who underwent LSG with tube calibrations. LSG with large sleeve volume showed a slight weight gain during 5 years of observation. A total of 16 patients (13.3%) underwent a second stage procedure within a period of 5 years (2 redo-sleeves, 7 LBPD-DS, 3 LRYGBP). Conclusion Early weight loss results were not different between the groups, but after 2 years the more restrictive LSG (groups 2, 3) results were significantly better than in patients without calibration. A removed gastric volume of < 500 cc seems to be a predictor of failure in treatment or early weight regain. A statistically significant improved health status and quality of life were registered for all groups. The general introduction of LSG as a one-stage restrictive procedure in the bariatric field can be considered only if the procedure is standardized and long-term results are available.     

Laparoscopic Sleeve Gastrectomy is Superior to Endoscopic Intragastric Balloon as a First Stage Procedure for Super-Obese Patients (BMI ≥50)

The treatment of patients with a BMI ≥50 kg/m² is still controversial. Given the many co-morbidities and oftentimes fragile health of super-obese patients, surgeons experienced in bariatrics often advocate a less invasive first stage operation for these patients. This allows them enough weight loss to support a more major second-stage operation such as a gastric bypass or a biliopancreatic diversion / duodenal switch. Thus, the aim of this study was to compare laparoscopic sleeve gastrectomy (LSG) and the BioEnterics intragastric balloon (BIB) as a first-stage procedure for effective initial weight loss before more definitive surgery. Methods: 20 patients (13 males and 7 females) who underwent LSG from May 2001 to December 2002 were compared with 57 patients (33 males and 24 females) obtained as historical controls from two large series who underwent BIB. Patients were evaluated at 6 months in terms of: weight, BMI, percent of excess weight loss (%EWL) and change in BMI. Results: There were no differences between groups for age, weight and BMI. There were no complications for patients under-going the LSG. For patients undergoing BIB, 4 patients (7%) had the balloon removed due to intolerance. The mean weight loss for patients undergoing LSG and BIB at 6 months was 45.5 vs 22.3 kg respectively, and the %EWL was 35 for LSG vs 24 for BIB. BMI decreased respectively from 69 to 53 for the LSG group and from 59 to 51 for the BIB group. Weight loss decreased co-morbidities in 90% of patients after both procedures. Conclusion: Patients undergoing a LSG showed a faster and greater weight loss than those using a BIB at 6 months. Moreover, LSG is a safe procedure, with reproducible results, in contrast to the BIB which was tolerated by 93% of patients. The results indicate that both mean weight loss and %EWL were better in the LSG group, and that BMI decreased substantially more in the LSG group as well. Although the BIB procedure shows efficacy in reducing weight, the LSG group does so faster and to a greater amount, thus suggesting that this may be a superior procedure as a first stage for super-obesity.     

Laparoscopic Treatment of Obese Patients with Gastroesophageal Reflux Disease and Barrett’s Esophagus: a Prospective Study

Background  

Short-segment Barrett’s esophagus (SSBE) or long-segment Barrett’s esophagus (LSBE) is the consequence of chronic gastroesophageal reflux disease (GERD), which is frequently associated with obesity. Obesity is a significant risk factor for the development of GERD symptoms, erosive esophagitis, Barrett’s esophagus, and esophageal adenocarcinoma. Morbidly obese patients who submitted to gastric bypass have an incidence of GERD as high as 50% to 100% and Barrett’s esophagus reaches up to 9% of patients.     

Mapping of Ghrelin Gene Expression and Cell Distribution in the Stomach of Morbidly Obese Patients—a Possible Guide for Efficient Sleeve Gastrectomy Construction

Background  

Ghrelin is secreted mainly in the stomach and plays a role in food intake regulation. Morbidly obese (MO) individuals report a decline in appetite after sleeve gastrectomy (SG), presumably due, in part, to ghrelin cell removal. Ghrelin cell distribution and expression were determined in three areas of resected stomach specimens from MO patients subjected to SG.     

Laparoscopic Roux-en-Y Gastric Bypass Versus Laparoscopic Sleeve Gastrectomy for the Treatment of Morbid Obesity. A Prospective Study with 5 Years of Follow-Up

Background

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is one of the most widely used bariatric procedures today, and laparoscopic sleeve gastrectomy (LSG) is becoming increasingly popular. The aim of this study was to compare mid-term results of both procedures.

Methods

From January 2008 to December 2008, 117 obese patients were assigned by patient choice after informed consent to either a LRYGB procedure (n?=?75) or a LSG procedure (n?=?42). We determined operative time, length of stay, morbidity, comorbidity outcomes, failures, and excess weight loss at 5 years.

Results

Both groups were comparable in demographic characteristics and comorbidities at baseline. No significant statistical differences were found in length of stay and early major morbidity, but mean operative time was shorter in LSG group, p?p?>?0.05. Five years after surgery, the percentage of excess weight loss was similar in both groups (69.8 % for LRYGB and 67.3 % for LSG, p?>?0.05). Failures were more common for LSG group, 22.2 versus 12.7 % for LRYGB group, but this difference was not significant, p?>?0.05.

Conclusions

Both techniques are comparable regarding safety and effectiveness after 5 years of follow-up, so not one procedure is clearly superior to the other.     

Thirty-Day Readmission After Laparoscopic Sleeve Gastrectomy—a Predictable Event?

Background

Thirty-day readmission post-bariatric surgery is used as a metric for surgical quality and patient care. We sought to examine factors driving 30-day readmissions after laparoscopic sleeve gastrectomy (LSG).

Methods

We reviewed 1257 LSG performed between March 2012 and June 2014. Readmitted and nonreadmitted patients were compared in their demographics, medical histories, and index hospitalizations. Multivariable regression was used to identify risk factors for readmission.

Results

Forty-five (3.6 %) patients required 30-day readmissions. Forty-seven percent were readmitted with malaise (emesis, dehydration, abdominal pain) and 42 % with technical complications (leak, bleed, mesenteric vein thrombosis). Factors independently associated with 30-day readmission include index admission length of stay (LOS) ≥3 days (OR 2.54, CI?=?[1.19, 5.40]), intraoperative drain placement (OR 3.11, CI?=?[1.58, 6.13]), postoperative complications (OR 8.21, CI?=?[2.33, 28.97]), and pain at discharge (OR?8.49, CI?=?[2.37, 30.44]). Patients requiring 30-day readmissions were 72 times more likely to have additional readmissions by 6 months (OR?72.4, CI?=?[15.8, 330.5]).

Conclusions

The 30-day readmission rate after LSG is 3.6 %, with near equal contributions from malaise and technical complications. LOS, postoperative complications, drain placement, and pain score can aid in identifying patients at increased risk for 30-day readmissions. Patients should be educated on postoperative hydration and pain management, so readmissions can be limited to technical complications requiring acute inpatient management.

     

Laparoscopic Sleeve Gastrectomy��Radiological Assessment of Fundus Size and Sleeve Voiding

Background

Laparoscopic sleeve gastrectomy (LSG) is now considered an effective bariatric procedure (American Society for Metabolic and Bariatric Surgery statement). We attempted to assess the size of the gastric fundus remaining after LSG and gastric voiding rate (fast/slow) by radiological upper gastrointestinal series (UGS) with a water-soluble contrast medium (CM). The findings were compared with weight loss data.

Methods

Seventy-four obese patients underwent LSG. Radiological UGS were used to measure the remaining fundus size in 28 of 74 patients 24?C72 h after the procedure, with the aid of Matlab software and a library image processing toolbox (MathWorks®). Sleeve voiding was measured in 57 of 74 patients, based on the patients?? radiological reports.

Results

The mean volume of the remaining fundus was 17.56 ml (range 1.00?C77.03 ml). The mean percent excess BMI loss (%EBL) was 39.5%, 53.7%, and 60.8%, respectively, 3, 6, and 12 months after LSG. Sleeve voiding was fast in 49 of 57 patients (85.96%) and slow in eight (14.03%).

Conclusions

No correlation was found between the estimated volume of the remaining gastric fundus and weight loss (%EBL) after LSG. Patients showing a rapid gastroduodenal transit of the CM achieved a better weight loss than patients with a slow voiding rate.     

Impact of Laparoscopic Sleeve Gastrectomy and Laparoscopic Gastric Bypass on HbA1c Blood Level and Pharmacological Treatment of Type 2 Diabetes Mellitus in Severe or Morbidly Obese Patients. Results of a Multicenter Prospective Study at 1 Year

Gastric bypass (GBP) has proved its efficacy 30 years ago in the management of diabetes mellitus (T2DM) for severe obese patients. More recently, interesting results have been published after sleeve gastrectomy (SG) in the same indication. Between 2005 and 2008, three bariatric centers have prospectively collected the data of T2DM patients treated by laparoscopic gastric bypass (LGBP) or laparoscopic sleeve gastrectomy (LSG). Effects on hemoglobin A1c (HbA1c), pharmacological treatment and excess weight loss after 1 year of surgery have been analyzed. All patients (35 LGBP and 33 LSG) were treated with oral anti-diabetics (OAD) or insulin before surgery (32 OAD and three insulin in LGBP group and 27 OAD and six insulin in LSG group). The average body mass index (BMI) in the LGBP group was 47.9 and 50.6 kg/m2 in the LSG group. At 1 year after surgery, the average HbA1c lost was 2,537 in the GBP group and 2,175 in the SG group. T2DM had resolved (withdrawal of pharmacological treatment) in 60% of the LGBP group and 75.8% of the LSG group. Reduced use of pharmacological therapy was noted in 31.42% of the LGBP group and 15.15% of the LSG group. Percentage excess weight loss and BMI lost were 56.35% and 29.75% in the LGBP group and 60.11% and 29.80% in the LSG group, respectively. During short-term follow-up, the impact on regulation of HbA1c blood level of LGBP or LSG is important. At 1 year after surgery, LSG seems to be as effective as LGBP for the management of T2DM in severely obese patients.     

Investigating Nutritional Deficiencies in a Group of Patients 3 Years Post Laparoscopic Sleeve Gastrectomy

Background

Laparoscopic sleeve gastrectomy (LSG) as a single-stage procedure has shown to be effective in achieving significant weight loss and resolving obesity-related co-morbidities. However, its nutrition consequences have not been extensively explored. This study aims to investigate weight loss and evolution of nutritional deficiencies in a group of patients 3 years post LSG.

Methods

Retrospective data of a group of patients, 3 years following LSG as a stand-alone procedure was collected. Data included anthropometry, nutritional markers (hemoglobin, iron studies, folate, calcium, iPTH, vitamins D, and B₁₂), and compliancy with supplementations.

Results

Ninety-one patients (male/female; 28:63), aged 51.9?±?11.4 years with a BMI of 42.8?±?6.1 kg/m² were identified to be 3 years post LSG. Percentage of weight loss at 1 and 3 years post-operatively was 29.8?±?7.0 and 25.9?±?8.8 %, respectively. Pre-operatively, the abnormalities included low hemoglobin (4 %), ferritin (6 %), vitamin B₁₂ (1 %), vitamin D (46 %), and elevated iPTH (25 %). At 3 years post-operatively, the abnormal laboratory values included low hemoglobin (14 % females, P?=?0.021), ferritin (24 %, P?=?0.011), vitamin D (20 %, P?=?0.018), and elevated iPTH (17 %, P?=?0.010). Compliancy with multivitamin supplementation was noted in 66 % of patients.

Conclusion

In these patients, LSG resulted in pronounced weight loss at 1 year post-operatively, and most of this was maintained at 3 years. Nutritional deficiencies are prevalent among patients prior to bariatric surgery. These deficiencies may persist or exacerbate post-operatively. Routine nutrition monitoring and supplementations are essential to prevent and treat these deficiencies.

     

Endoscopic Sleeve Gastroplasty,Laparoscopic Sleeve Gastrectomy,and Laparoscopic Band for Weight Loss: How Do They Compare?

Background

Endoscopic sleeve gastroplasty (ESG) is a novel endobariatric procedure. Initial studies demonstrated an association of ESG with weight loss and improvement of obesity-related comorbidities. Our aim was to compare ESG to laparoscopic sleeve gastrectomy (LSG) and laparoscopic adjustable gastric banding (LAGB).

Methods

We included 278 obese (BMI > 30) patients who underwent ESG (n = 91), LSG (n = 120), or LAGB (n = 67) at our tertiary care academic center. Primary outcome was percent total body weight loss (%TBWL) at 3, 6, 9, and 12 months. Secondary outcome measures included adverse events (AE), length of stay (LOS), and readmission rate.

Results

At 12-month follow-up, LSG achieved the greatest %TBWL compared to LAGB and ESG (29.28 vs 13.30 vs 17.57%, respectively; p < 0.001). However, ESG had a significantly lower rate of morbidity when compared to LSG or LAGB (p = 0.01). The LOS was significantly less for ESG compared to LSG or LAGB (0.34 ± 0.73 vs 3.09 ± 1.47 vs 1.66 ± 3.07 days, respectively; p < 0.01). Readmission rates were not significantly different between the groups (p = 0.72).

Conclusion

Although LSG is the most effective option for weight loss, ESG is a safe and feasible endobariatric option associated with low morbidity and short LOS in select patients.