A Prospective Randomized Study Comparing Patients with Morbid Obesity Submitted to Laparotomic Gastric Bypass with or without Omentectomy

Background  Visceral fat, especially the greater omentum, seems to be an important factor in the development of some metabolic disturbances such as insulin resistance, hyperglycemia, and dyslipidemia. Therefore, we wanted to evaluate the influence of resecting or leaving in situ the greater omentum in a group of patients with morbid obesity. Methods  Seventy patients with morbid obesity were submitted to laparotomic resectional gastric bypass and an omentectomy was randomly performed in some patients. Body mass index (BMI), serum levels of sugar, insulin, total cholesterol, and triglycerides were determined prior to surgery and followed up on for 2 years afterwards. Results  Two years after surgery, no differences were seen in BMI levels in either group. Blood sugar levels, serum insulin, total cholesterol levels, and serum triglycerides had similar values in both groups. Arterial hypertension had similar behavior. Conclusions  Based on these results, omentectomy is not justified as part of bariatric surgery. Its theoretical advantages are not reflected in this prospective random trial.     

A Prospective Randomized Study Comparing Two Different Techniques for Laparoscopic Sleeve Gastrectomy

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) represents a relatively new restrictive operation for obesity. We report a prospective randomized study comparing two different techniques of performing this procedure. METHODS: Between January and August 2006, 20 patients (group A) and 20 patients (group B) were prospectively and randomly submitted to LSG. The characteristics of the patients in the two groups were similar for age and sex. The median preoperative weight was of 120 kg (95-180) (A) and 133 kg (83-175) (B) (NS). The median preoperative BMI was of 42.5 kg/m2 (35-58) (A) and 47 kg/m2 (37-58) (B) (NS). The two techniques differ in that in A, stapling is performed after full devascularization and mobilization of the gastric curve, whereas in B stapling is performed as soon as the lesser sac is entered and the greater curve is devascularized after full completion of the sleeve. The staple-line is reinforced at the end of stapling in both techniques. RESULTS: Median operative time was 34 min (12-54) (A) and 25 min (9-51) (B) (P = 0.06). Median peroperative bleeding was 5 mL (0-450) (A) and 5 mL (0-100) (B) (P = 0.37). Median number of staple cartridges used was 6 (5-7) (A) and 6 (4-7) (B) (P = 0.63). Peroperative complications were a small hiatal hernia requiring repair and a bleeding in two patients of A. Postoperative leak occurred in 1 patient of A, and minor early complications affected 2 patients of A and 1 patient of B. Peroperative and postoperative mortality was 0. Median hospital stay was 3 days (1-10) (A) and 3 days (2-7) (B) (P = 0.59). One stenosis as a late complication appeared in a patient of B. %EWL at 6 months and 1 year was respectively 43.4% (A), 42.2% (B) and 48.3% (A) 49.5% (B) (P = 0.82). CONCLUSION: LSG can be performed by two different techniques. The technique B (section of the stomach followed by its mobilization) appears familiar to surgeons usually performing laparoscopic RYGBP. No observed differences are significant, but the technique B when looking at observed distributions, seems to be better than the technique A (mobilization of the stomach followed by its section) in terms of operative time, peroperative bleeding and hospital stay.     

Experience with Laparoscopic Sleeve Gastrectomy for Morbid Versus Super Morbid Obesity

Background  

We evaluated the safety and efficacy of laparoscopic sleeve gastrectomy (LSG) for super morbid obesity in patients with an initial body mass index (BMI) of <50 or ≥50.     

Impact of Extent of Antral Resection on Surgical Outcomes of Sleeve Gastrectomy for Morbid Obesity (A Prospective Randomized Study)

Background

Laparoscopic sleeve gastrectomy (LSG) is a surgical technique that treats morbid obesity.

Methods

Consecutive patients with morbid obesity treated by LSG at our department were evaluated. Patients enrolled in the study were randomized into group I (LSG begins the division 2 cm from the pylorus) and group II (LSG begins the division 6 cm from the pylorus). The primary outcome measure was the percent of excess weight loss (% EWL); secondary outcomes included postoperative morbidity and mortality and improvement of comorbidity.

Results

One hundred five patients (79 (75.2 %) were females) were randomized into two groups of (GI) 52 patients and (GII) 53 patients. In group I, the mean % EWL was 51.8?±?13.9, 63.8?±?16.1 and 71.8?±?12; however, in group II, the mean % EWL was 38.3?±?10.9, 51.9?±?13.6 and 61?±?11.1 at 6, 12, and 24 months, respectively (P?=?0.0001, 0.0001, 0.003). There was weight regain after 2 years in five patients in group II and only one patient in group I (P?=?0.09). There was no significant difference between both group as regards gastric leakage, vomiting or GER. There was significant improvement in comorbidity after LSG in both groups, but no significant difference between them. Hospital mortality occurred in group II in one case as a result of gastric leakage.

Conclusions

LSG is a safe and effective procedure with good short-term outcome. Increasing the size of the resected antrum is associated with better weight loss without increasing the rate of complications significantly.     

A Review of Laparoscopic Sleeve Gastrectomy for Morbid Obesity

Laparoscopic sleeve gastrectomy (LSG) is an innovative approach to the surgical management of morbid obesity. Weight loss may be achieved by restrictive and endocrine mechanisms. Early data suggest LSG is efficacious in the management of morbid obesity and may have an important role either as a staged or definitive procedure. A systematic review of the literature analyzing the clinical and operational outcomes of LSG was completed to further define the status of LSG as an emerging treatment modality for morbid obesity. Data from LSG were compared to benchmark clinical data and local operational data from laparoscopic adjustable gastric band (LAGB) and laparoscopic gastric bypass (LRYGB). Fifteen studies (940 patients) were identified following systematic review. The percent excessive weight loss (%EWL) for LSG varied from 33% to 90% and appeared to be sustained up to 3 years. The mortality rate was 0-3.3% and major complications ranged from 0% to 29% (average 12.1%). Operative time ranged from 49 to 143 min (average 100.4 min). Hospital stay varied from 1.9 to 8 days (average 4.4 days). The operational impact of LSG has not been described in the literature. According to data from the Royal Alexandra Hospital, the estimated total cost of LSG was 10,317 CAD as compared to LAGB (10,317 CAD as compared to LAGB (7,536 CAD) and LRYGB ($11,666 CAD). These costs did not include further surgical interventions which may be required for an undefined group of patients after LSG. Early, non-randomized data suggest that LSG is efficacious in the surgical management of morbid obesity. However, it is not clear if weight loss following LSG is sustainable in the long term and therefore it is not possible to determine what percent of patients may require further revisional surgery following LSG. The operational impact of LSG as a staged or definitive procedure is poorly defined and must be analyzed further in order to establish its overall health care costs and operational impact. Although LSG is a promising treatment option for patients with morbid obesity, its role remains undefined and it should be considered an investigational procedure that may require revision in a subset of patients.     

Addressing Morbid Obesity as a Barrier to Renal Transplantation With Laparoscopic Sleeve Gastrectomy

Morbid obesity is a barrier to renal transplantation and is inadequately addressed by medical therapy. We present results of a prospective evaluation of laparoscopic sleeve gastrectomy (LSG) for patients failing to achieve significant weight loss with medical therapy. Over a 25‐month period, 52 obese renal transplant candidates meeting NIH guidelines for metabolic surgery underwent LSG. Mean age was 50.0 ± 10.0 years with an average preoperative BMI of 43.0 ± 5.4 kg/m² (range 35.8–67.7 kg/m²). Follow‐up after LSG was 220 ± 152 days (range 26–733 days) with last BMI of 36.3 ± 5.3 kg/m² (range 29.2–49.8 kg/m²) with 29 (55.8%) patients achieving goal BMI of <35 kg/m² at 92 ± 92 days (range 13–420 days). The mean percentage of excess weight loss (%EWL) was 32.1 ± 17.6% (range 6.7–93.8%). A segmented regression model was used to compare medical therapy versus LSG. This revealed a statistically significant increase in the BMI reduction rate (0.3 kg/m²/month versus 1.1 kg/m²/month, p < 0.0001). Patients also experienced a 40.9% decrease in anti‐hypertensive medications (p < 0.001) and a 49.7% decrease in total daily insulin dose (p < 0.001). LSG is a safe and effective means for addressing obesity in kidney transplant candidates in the context of a multidisciplinary approach.     

Initial Experience with Robotic Sleeve Gastrectomy for Morbid Obesity

Background  

Laparoscopic sleeve gastrectomy (LSG) is used with increasing frequency for the treatment of morbid obesity. The application of robotic techniques has been reported for bariatric operations like laparoscopic Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding, but not for LSG. We report herein our initial experience with LSG performed with the use of the Da Vinci surgical system.     

Laparoscopic Roux-en-Y Gastric Bypass Versus Laparoscopic Sleeve Gastrectomy for the Treatment of Morbid Obesity. A Prospective Study of 117 Patients

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is one of the most widely used bariatric procedures today, and laparoscopic sleeve gastrectomy (LSG) as a single-stage procedure for the treatment of morbid obesity is becoming increasingly popular. In this study, we prospectively compared both techniques in order to establish whether there is any superiority of one over the other based on morbidity and effectiveness. From January 2008 to December 2008, 117 obese patients with indication for bariatric surgery 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, co-morbidity outcomes, and excess weight loss at 1 year postoperative. Both groups were comparable in age, sex, body mass index, and co-morbidities. Mean operative time of LSG was 82 min while LRYGB was 98 min (p < 0.05). Differences in length of stay, major complications, improvement in co-morbidities, and excess weight loss were not significant (p > 0.05). One year after surgery, average excess weight loss was 86% in LRYGB and 78.8% in LSG (p > 0.05). In the short term, both techniques are comparable regarding safety and effectiveness, so not one procedure is clearly superior to the other.     

Hepatic Histopathology of Patients with Morbid Obesity Submitted to Gastric Bypass

Background: The authors analyze and describe the hepatic histopathology of patients with morbid obesity submitted to gastric bypass. Methods: A liver biopsy was performed in 112 patients at the beginning of gastric bypass, and clinical data (gender, age, BMI and associated diseases) were obtained from the patient records. Results: Among the patients, 74.1% (n=83) were females and 25.9% (n=29) were males, age 39.59±10.12 years, with BMI 48.79±7.54. Regarding the diseases associated with morbid obesity, arterial hypertension was observed in 67.9% (n=76) of the patients, joint diseases in 55.4% (n=62), dyslipidemia in 40.2% (n=45), and diabetes type 2 in 27.7% (n=31). 111 patients (99.1%) showed different types of non-alcoholic fatty liver disease (NAFLD) (types 1, 2, 3 and 4), with types 3 and 4 accounting for 57.7% (n=64). A significant association was observed between NAFLD type 4 and diabetes type 2 (P=0.018). The presence of glycogen nuclei was significantly correlated with steatosis (P=0.000), lobular inflammation (P=0.019) and perisinusoidal fibrosis (P=0.000). Conclusion: 1) Liver biopsy taken at gastric bypass reveals different types of NAFLD; 2) Diabetes type 2 is associated with NAFLD type 4; 3) Glycogen nuclei are correlated with steatosis, lobular inflammation and perisinusoidal fibrosis; 4) Steatosis represents the basic injury in NAFLD and is associated with hepato-cellular ballooning. 5) In view of the frequency of hepatic alterations, a biopsy should be part of the surgical protocol of morbid obesity, this method being the only one able to determine the presence of lesions and to stage fibrosis.     

Improvement in Cardiovascular Indices After Roux-en-Y Gastric Bypass or Sleeve Gastrectomy for Morbid Obesity

Background

Morbidly obese patients display cardiac abnormalities which are partially reversed after weight loss. The aim of the present study was to assess the potential difference in cardiovascular disease indices between patients who underwent either gastric bypass surgery or sleeve gastrectomy.

Methods

Thirty-seven morbidly obese patients who underwent either Roux-en-Y gastric bypass (RYGB) (n?=?14) or SG (n?=?23) were examined before, 3 and 6 months after surgery. Indices of cardiac autonomic nervous system activity were evaluated, namely baroreflex sensitivity (BRS) and heart rate variability (HRV). A complete echocardiographic study was performed in a subgroup of 17 patients (RYGB 8, SG 9) preoperatively and 6 months after surgery, evaluating epicardial fat thickness, aortic distensibility, left ventricular (LV) Tei index, left atrium diameter, ejection fraction, and LV mass.

Results

All subjects experienced significant (p?<?0.001) and similar weight loss independently of the type of operation. BRS and HRV indices improved significantly and to the same degree after surgery in both groups. In the echocardiographic study, all parameters improved significantly at 6 months in comparison with the baseline values. In addition, the RYGB group displayed significantly greater reduction in epicardial fat thickness (p?=?0.007) and also tended to have a better LV performance as expressed by the lower values of the Tei index (p?=?0.06) compared to the SG group 6 months after surgery.

Conclusions

Both RYGB and SG exert comparable effects on weight loss and improvement of cardiovascular parameters. RYGB displays a more beneficial influence on epicardial fat thickness and left ventricular performance than SG.     

Functional Importance of Laparoscopic Sleeve Gastrectomy for the Lower Esophageal Sphincter in Patients with Morbid Obesity

Background  

Obesity is characterized by excess body fat measured in body mass index (BMI), which is the weight in kilograms (kg) divided by the height in square meters [m²]. In the Northern Hemisphere, the prevalence of overweight has increased by up to 34%. This situation is associated with high incidence of comorbidities such as gastroesophageal reflux disease. Bariatric surgery is the only effective treatment for severe obesity, resulting in amelioration of obesity comorbidities. Data on LES competence following sleeve gastrectomy (SG), one of the several bariatric procedures, are conflicting.     

Reinforcing the Staple Line During Laparoscopic Sleeve Gastrectomy: Prospective Randomized Clinical Study Comparing Three Different Techniques

Background

Gastric leak and hemorrhage are the most important challenges after laparoscopic sleeve gastrectomy (LSG). In order to reduce these complications, the staple line can be reinforced by absorbable sutures or by the use of glycolide trimethylene carbonate copolymer onto the linear stapler (Gore Seamguard®; W.L. Gore &; Associates, Inc, Flagstaff, AZ). To our knowledge, there are no randomized studies showing the utility of staple line reinforcement during LSG. The purpose of this study was to randomly compare three techniques in LSG: no staple line reinforcement (group 1), buttressing of the staple line with Gore Seamguard® (group 2), and staple line suturing (group 3).

Methods

Between January 2008 and February 2009, 75 patients were prospectively and randomly enrolled in the three different techniques of handling the staple line during LSG. The patient groups were similar (NS).

Results

Mean operative time to perform the stomach sectioning was 15.9?±?5.9 min (group 1), 20.8?±?8.1 min (group 2), and 30.8?±?10.1 min (group 3) (p?p?=?0.02). Mean blood loss during stomach sectioning was 19.5?±?21.3 mL (group 1), 3.6?±?4.7 mL (group 2), and 16.7?±?23.5 mL (group 3) (p?p?=?0.03). Mean number of stapler cartridges used was 5.6?±?0.7 (group 1), 5.7?±?0.7 (group 2), and 5.8?±?0.6 (group 3) (NS). Postoperative leak affected one patient (group 1), two patients (group 2), and one patient (group 3) (NS). Mean hospital stay was 3.6?±?1.4 days (group 1), 3.9?±?1.5 days (group 2), and 2.8?±?0.8 days (group 3) (p?=?0.01).

Conclusions

In LSG, buttressing the staple line with Gore Seamguard® statistically reduces blood loss during stomach sectioning as well as overall blood loss. No staple line reinforcement statistically decreases the time to perform stomach sectioning and the total operative time. No significant difference is evidenced in terms of postoperative leak between the three techniques of LSG.

     

A Prospective Study on Inflammatory Parameters in Obese Patients After Sleeve Gastrectomy

Different hormones and peptides involved in inflammation have been studied in and related to obesity. The aim of our work is to assess the variations of different molecules related to inflammation in obese patients during the first year following sleeve gastrectomy. This was a prospective study on patients who underwent sleeve gastrectomy. The variations in different clinical, anthropometric, and analytical parameters related to inflammation were determined and analysed in all patients at the preoperative visit and at the first and fifth days, first and sixth months, and 1 year following surgery. We enrolled 20 patients to the study. The median body mass index (BMI) before intervention was 48.5 kg/m². With respect to comorbidities, 70 % of the patients had obstructive sleep apnoea syndrome (OSA), 65 % high blood pressure, 45 % dyslipidaemia, and 40 % diabetes mellitus (DM). The median percentage of BMI lost (%BMIL) 1 year after the intervention was 71 %. The dyslipidaemia healing or improvement rate was 100 %, whereas it was 87.5 % for diabetes, 84.6 % for hypertension, and 57.1 % for OSA. During the 1-year postintervention period, the average levels of adiponectin increased, although not significantly, whereas those of leptin significantly decreased. In addition, the blood levels of MCP-1, IL-6, CRP, ferritin, and PAI-1 significantly decreased in that period. Sleeve gastrectomy is a surgical technique that is associated with improvements in body weight and comorbid conditions from the first postoperative months, which lead to significant variations in the levels of different inflammation-related parameters and a decrease in the levels of leptin, IL-6, CRP, MCP-1, ferritin, and serpin (PAI-1).     

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.

     

Laparoscopic Sleeve Gastrectomy for Morbid Obesity with Intra-operative Endoscopic Guidance. Immediate Peri-operative and 1-year Results after 25 Patients

Laparoscopic sleeve gastrectomy (LSG) represents a promising alternative option for the surgical treatment of morbid obesity. Its standard technique includes the longitudinal division of the stomach along a bougie of varying diameter. We report in this retrospective study our experience with LSG being performed with the use of intra-operative endoscopy instead of the bougie. Twenty-five consecutive patients (18 women, seven men) with a mean age of 40.2 years and mean body weight of 152.1 kg were submitted to LSG with intra-operative endoscopy in our hospital. The mean preoperative BMI was 53.5 kg/m². There were no conversions. Mean operative time was 117.5 min. There was no morbidity or mortality. The mean loss of excess body weight (EBW) at 3 months post-op was 19 ± 1.8 kg, at 6 months was 28.6 ± 4.5 kg, and at 1 year post-op was 48.9 ± 3.7 kg (min 11–max 92). In other words the patients had lost 30 ± 5%, 45 ± 7.7%, and 60.8 ± 4.3% of their EBW, respectively. The mean excess body weight loss at the day of the last visit to our outpatient clinic was 52.3 ± 4.3 kg which corresponded to 66.4 ± 4.3% of the total excess weight. LSG with intra-operative endoscopic guidance is a safe and efficient alternative method to treat morbid obesity and is a viable option for surgical units familiar with endoscopic techniques.     

Management of Leaks After Laparoscopic Sleeve Gastrectomy in Patients with Obesity

Introduction  

Laparoscopic sleeve gastrectomy (LSG) is a surgical procedure that is being increasingly performed on obese patients. The most frequent postoperative complication is the appearance of a gastric leak.     

Reinforcing the Staple Line During Laparoscopic Sleeve Gastrectomy: Prospective Randomized Clinical Study Comparing Two Different Techniques. Preliminary results

Background  

Sleeve gastrectomy involves the creation of small gastric reservoir based on lesser curvature of the stomach, which is fashioned by a longitudinal gastrectomy that preserves the antrum and pylorus together with its vagal innervation. The main complications in the early postoperative course are bleeding and gastric leak. In order to reduce these complications the staple line can be reinforced in many different ways. The purpose of this study was to randomly compare two different techniques in laparoscopic sleeve gastrectomy (LSG): buttressing the staple line at the gastroesophageal junction (angle of Hiss) with Gore Seamguard and staple-line suturing with PDS 2.0.     

A Prospective Randomized Controlled Trial of the Metabolic Effects of Sleeve Gastrectomy with Transit Bipartition

Purpose

To compare the effects of the sleeve gastrectomy with transit bipartition (SG?+?TB) procedure with standard medical therapy (SMT) in mildly obese patients with type II diabetes (T2D).

Methods

This is a prospective, randomized, controlled trial. Twenty male adults, ≤?65 years old, with T2D, body mass index (BMI)?>?28 kg/m² and <?35 kg/m², and HbA1c level?>?8% were randomized to SG?+?TB or to SMT. Outcomes were the remission in the metabolic and cardiovascular risk variables up to 24 months.

Results

At 24 months, SG?+?TB group showed a significant decrease in HbaA1c values (9.3?±?2.1 versus 5.5?±?1.1%, P?=?<?0.05) whereas SMT group maintained similar levels from baseline (8.0?±?1.5 versus 8.3?±?1.1%, P?=?NS). BMI values were lower in the SG?+?TB group (25.3?±?2.8 kg/m² versus 30.9?±?2.5 kg/m²; P?=?<?0.001). At 24 months, none patient in SG?+?TB group needed medications for hyperlipidemia/hypertension. HDL-cholesterol levels increased in the SG?+?TB group (33?±?8 to 45?±?15 mg/dL, P?<?0.001). After 24 months, the area under the curve (AUC) of GLP1 increased and in the SG?+?TB group and the AUC of the GIP concentrations was lower in the SG?+?TB group than in the SMT. At 3 months, SG?+?TB group showed a marked increase in FGF19 levels (74.1?±?45.8 to 237.3?±?234 pg/mL; P?=?0.001).

Conclusions

SG?+?TB is superior to SMT and was associated with a better metabolic and cardiovascular profile.