Technical Aspects of Laparoscopic Sleeve Gastrectomy in 25 Morbidly Obese Patients

Background Laparoscopic sleeve gastrectomy (LSG) has recently come to be performed as a sole bariatric operation. The postoperative morbidity and mortality are cause for concern, and possibly are related to non-standardized surgical technique. Methods The following is the surgical LSG technique used in 25 morbidly obese patients. Five trocars are used. Division of the vascular supply of the greater gastric curvature is begun at 6–7 cm proximal to the pylorus, proceeding to the angle of His. A 50-Fr calibrating bougie is positioned against the lesser curvature. The LSG is created using a linear staplercutter device with one 4.1-mm green load for the antrum, followed by five to seven sequential 3.5-mm blue loads for the remaining gastric corpus and fundus. The staple-line is inverted by placing a seroserosal continuous absorbable suture over the bougie from the angle of His .The resected stomach is removed through the 12-mm trocar, and a Jackson-Pratt drain is left along the suture-line. Results The mean operative time was 120 minutes, and length of hospital stay was 4 ± 2 days.There were no conversions to open procedures. There were no postoperative complications (no hemorrhage from the staple-line, no anastomotic leakage, no stricture) and no mortality. In 1 patient, cholecystectomy was also done, and in 4, a gastric band was removed. During a median follow-up of 4 months, BMI decreased from 43 ± 5 kg/m² to 34 ± 6 kg/m², and the % excess BMI loss was 49 ± 25%. Conclusions The proposed surgical technique appears to be a safe and effective procedure for morbid obesity.     

Superior Mesenteric Artery Syndrome after Laparoscopic Sleeve Gastrectomy

Superior mesenteric artery syndrome is a duodenal obstructive complication, which has been reported after Roux-en-Y gastric bypass. We report a patient who presented a fistula at the angle of His after a laparoscopic sleeve gastrectomy, which was treated with endoscopic procedures and laparoscopic drainage. During this period, there was excessive, rapid weight loss to BMI 22 kg/m². At 3 months after the fistula had closed, metrorrhagia was treated by blood transfusion and urgent hysterectomy. Following this, diarrhea occurred and worsened the malnutrition, and the BMI was 18. Duodenal obstruction occurred, confirmed by radiological studies and endoscopy. Duodenojejunostomy and choleystectomy were done, and there has been no recurrence of duodenal obstruction in the 14 follow-up months.     

Gastric tube volume after duodenal switch and its correlation to short-term weight loss

Background Bariatric operations may have a restrictive and a malabsorptive component. The restrictive component is considered key for short-term weight loss. However, there are important volume discrepancies between gastric reservoirs in different bariatric surgical techniques, which questions the real meaning of the restrictive part of the operation. We have investigated the relationship between residual gastric volume after sleeve gastrectomy in duodenal switch (DS) and weight loss over the first postoperative year. Methods 14 patients submitted to a modified DS and one patient submitted to a sleeve gastrectomy were studied. All patients had an abdominal CT performed between the third and the ninth postoperative month to measure residual gastric volume. Gastric tube volume was correlated to early postoperative weight loss. Results Mean excess BMI loss was 75% at 12 months. Mean gastric tube volume was 208 cc. Gastric volume was not related to preoperative weight or BMI; instead, it was directly related to patient’s height. There was no statistical relation between gastric volume and weight loss at 3, 6, 9 or 12 months after the operation. Conclusion After DS, gastric tube volume is not directly related to weight changes. Other factors could have influence on intake restriction, such as gastric tube compliance or different mechanisms of satiety induction, because no differences in weight loss were observed between narrow tubes and wider ones, despite important variations in volume.     

Laparoscopic Sleeve Gastrectomy in Ethnic Obese Chinese

Background  The aim of this study was to evaluate the effectiveness and safety of laparoscopic sleeve gastrectomy (LSG) for the treatment of obesity in ethnic Chinese in Hong Kong. Methods  Seventy consecutive Chinese patients (49 females; mean age 34.7 ± 8.8 [range 18–56] years) received LSG for the treatment of obesity from May 2006 to Nov 2007 as a stand-alone procedure for weight reduction. Mean baseline body weight (BW) and body mass index (BMI) were 108.9 ± 22.1 kg (range 71.0–164.9 kg) and 40.7 ± 7.8 kg/m² (range 27.4–68.4 kg/m²), respectively. Outcome measures were collected and assessed in a prospective manner. Results  All procedures were performed laparoscopically with no conversion. There was neither mortality nor any postoperative complications that required reoperation. Major complication occurred in two patients (2.9%; esophagogastric junction [EGJ] leak and stomach tube stricture). Mean follow-up was 7.1 ± 5.0 months. Mean procedure time was 90.6 ± 39.4 min, and mean hospital stay was 3.8 ± 2.3 days. Mean BMI loss was 6.3 ± 2.5, 9.0 ± 3.4 and 12.3 ± 4.5 kg/m² at 3, 6, and 12 months. Mean percent of excess BW loss was 48.5 ± 28.4, 69.7 ± 31.7, and 63.5 ± 29.4 at 3, 6, and 12 months. Conclusion  LSG is safe and effective in achieving significant weight loss in obese ethnic Chinese patients.     

Laparoscopic Sleeve Gastrectomy: Surgical Technique, Indications and Clinical Results

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) has been introduced as a multipurpose restrictive procedure for obese patients. Variations of the surgical technique may be important for the late results. METHODS: 50 patients submitted to LSG from January 2005 to December 2006 were studied. Mean age was 38.2 years, preoperative weight was 103.4 +/- 14.1 kg (78 to 146 kg), and preoperative BMI was 37.9 +/- 3.4 (32.9 to 46.8). Important co-morbidities were present in 39 patients (78%). RESULTS: Operative time was 110 +/- 15 min. Intraoperative difficulties were observed in 7 patients. Volume of the resected specimen was 760 +/- 55 ml and capacity of the gastric remnant was 108.5 +/- 25 ml. There was no conversion to open surgery. Histology of the resected stomach was normal in 8 patients, while chronic gastritis was found in 42 patients. At 6 and 12 months postoperatively, weight loss was 28.0 +/- 6.4 kg and 32.6 +/- 6.8 kg respectively. In the 18 patients who have reached 1 year follow-up, % excess BMI loss reached 85 +/- 0.7%. Most of the medical diseases associated with the obesity resolved after 6 to 12 months. CONCLUSION: LSG may be an acceptable operation. It is easy to perform, safe, and has a lower complication rate than other bariatric operations. Further studies are necessary for the clinical results at long-term follow-up.     

Laparoscopic Sleeve Gastrectomy without an Over-Sewing of the Staple Line

Background  In the past few years, laparoscopic sleeve gastrectomy (LSG) became a widely used bariatric method. Based on results of recent LSG studies, LSG is being increasingly used even as a single bariatric method. On contrary with some other reports, we do not reinforce the LSG staple line with over-sewing. Our pilot study presents treatment outcomes and results 18 months after LSG. Methods  Sixty-one consecutive morbidly obese (MO) patients (19 male and 42 female) who underwent LSG from January 2006 to May 2008 were included into the study. The mean age, height, and weight were 37.3 years (29–57), 168 cm (151–187), and 118 kg (97–181), respectively, while mean body mass index (BMI) was 41.8 (36.1–60.4). LSG started at 6 cm from pylorus and ended at the angle of Hiss. For gastric sleeve calibration 38F, intragastric tube was used. All 61 LSG were performed without over-sewing of the staple line. In the last 24 cases, the staple line was covered with Surgicel™ strips, which were however placed without any fixation to the underlying gastric tissue. Results  Mean operating time was 105 min (80–170) and no conversion to open surgery. An 18-month follow-up was recorded in 39 MO patients. The mean weight loss was 31.3 (range, 21–67 kg) and mean % excess BMI loss reached 72% (range, 64–97%). Neither leak nor disruptions of the staple line and/or sleeve dilatation were recorded. Conclusion  LSG is an effective and safe bariatric procedure with low incidence of complications and mortality in our experience.     

Vertical Gastric Resection (Sleeve Gastrectomy) in a Morbidly Obese Patient with Past Jejunoileal Bypass

Jejunoileal bypass (JIB) is a purely malabsorptiveoperation, which has been abandoned in the USA andWestern Europe due to occasional serious complications.We are still seeing past JIB patients who havebecome obese again over the years, but are not sufferingside-effects of the previous JIB, and are complainingof typical co-morbidities of the obesity. Wepresent a prior JIB patient who underwent a sleevegastrectomy in 2003 for recurrence of morbid obesity.The patient has been followed for another 4 years withregular laboratory tests, monitoring of weight loss,bone densitometry and possible complications.Selected morbidly obese patients who have undergonepast JIB, can be safely treated by a restrictiveprocedure, sleeve gastrectomy, to accomplish successfulweight loss without increasing the risk of possibleserious complications.     

Use of a Roux Limb to Correct Esophagogastric Junction Fistulas after Sleeve Gastrectomy

Laparoscopic sleeve gastrectomy (LSG) can be complicated, in the early postoperative course, by an esophagogastric junction (EGJ) leak with very serious consequences. A 48-year-old woman developed an EGJ leak 3 days after LSG surgery and was treated with conservative measures. Finally, 6 weeks after the original surgery, a Roux limb was brought to the EGJ and anastomosed side-to-end to the fistula. At the beginning, the Roux limb was the only functioning outlet and finally, 2 months later, both pathways (the gastric sleeve and the Roux-en-Y) are patent at 3 months after surgery. The Roux limb resolved a dangerous EGJ leak after a LSG.     

Mid-term Follow-up after Sleeve Gastrectomy as a Final Approach for Morbid Obesity

Background  In previous publications, we demonstrated the safety and short-term efficacy of laparoscopic sleeve gastrectomy (LSG) as a final step in the treatment of morbid obesity (MO). This study aimed to assess the mid-term efficacy of LSG. Methods  We performed a retrospective review of a prospectively collected database. Between November 2004 and January 2007, 130 consecutive patients underwent LSG as a final procedure to MO. Data including patient demographics, operative time, length of hospital stay, complications, preoperative body mass index (BMI), complications, and weight loss at 3, 6, 12, 18, and 24 months were recorded and analyzed. Results  The mean age was 45.6 (range: 12–79) years while the mean BMI was 43.2 (range: 30.2–75.4) kg/m². The mean operative time was 97 (range, 58–180) min and all operations were completed laparoscopically. The mean hospital stay was 3.2 (range, 1–19) days with zero mortality in this series. One patient (0.7%) had leakage at the stapler line, while four patients (2.8%) developed trocar site infection. Three patients (2.1%) complained of symptoms of gastroesophageal reflux disease (GERD), three patients (2.1 %) developed symptomatic gallstones, and trocar site hernia was present in one (0.7%) patient. The mean weight loss was 21, 31.2, 37.4, 39.5, and 41.7 kg at 3, 6, 12, 18, and 24 months, respectively, while the mean BMI decreased to 36.9, 32.8, 29.5, 28, and 27.1 at 3, 6, 12 18, and 24 months, respectively. Percent of excess weight loss (%EWL) was 33.1, 50.8, 62.2, 64.4, and 67.9 at 3, 6, 12, 18, and 24 months, respectively. Conclusions  LSG is a safe and effective surgical procedure for the morbidly obese up to 2 years. Excess body weight loss seems to be acceptable at 2 years postoperatively.     

Single Incision Laparoscopic Sleeve Gastrectomy (SILS): A Novel Technique

Background  Laparoscopic sleeve gastrectomy is an emerging bariatric procedure that typically necessitates five to seven small skin incisions to place five to seven trocars. The senior author (Saber) has developed a single umbilical incision approach to laparoscopic sleeve gastrectomy. Methods  Seven patients underwent single access transumbilical laparoscopic sleeve gastrectomy between March 2008 and July 2008. The same surgeon performed all surgical interventions. The umbilicus was the sole point of entry for all patients, and the same operative technique and perioperative protocol were used in all patients. Results  A total of seven single-incision laparoscopic sleeve gastrectomies were performed. The procedure was successfully performed in all patients. Mean operating time was 125 min. None of the patients required conversion to an open procedure. There were no mortalities or postoperative complications noted during the mean follow-up period of 3.4 months. Conclusion  Single-incision transumbilical laparoscopic sleeve gastrectomy is safe, technically feasible, and reproducible.     

Midterm Results of Primary vs. Secondary Laparoscopic Sleeve Gastrectomy (LSG) as an Isolated Operation

Background  We investigated early and midterm results of laparoscopic sleeve gastrectomy (LSG) as an isolated primary and secondary operation after failed gastric banding. Methods  Between May 2004 and October 2007, a total of 70 patients (female 77%, mean age 43 (21–65) years, mean initial body mass index (BMI) 46 (35–61) kg/m²) were prospectively evaluated and operated by LSG. In 41 patients, LSG was performed as a primary operation (group 1) and in 29 patients as a secondary procedure after failed gastric banding (group 2). The overall average follow-up time after LSG was 24 (12–53) months; follow-up rate 1 year after operation was 100%, after 2 years 98%, and after 3 years 95%. Results  There were no intraoperative complications, no conversion with shorter operation time in group 1 (91 vs. 132 min, p = 0.001). Early morbidity of LSG was 5% (major) and 7% (minor); mortality was zero. Average excessive BMI loss after 1 year was 65% (9–127%), after 2 years 63% (13–123%), and after 3 years 60% (9–111%). Midterm morbidity was 13%. There was no significant difference between the two groups regarding early and midterm morbidity, reoperation rate for complications (11.4%), or insufficient weight loss (7%). Conclusions  LSG is a safe bariatric procedure with good weight loss in the first 3 years postop. It can be used as an isolated initial treatment and as a secondary treatment after failed gastric banding. However, in the absence of long-term results, we suggest LSG to be performed only in controlled trials.     

Short-term Effects of Sleeve Gastrectomy on Type 2 Diabetes Mellitus in Severely Obese Subjects

Background Data on the effectiveness of sleeve gastrectomy (SG) in improving or resolving type 2 diabetes mellitus (T2DM) are scarce. Methods A 4-month prospective study was conducted on the changes in glucose homeostasis in 35 severely obese T2DM subjects undergoing laparoscopic SG (LSG) and 50 subjects undergoing laparoscopic Roux-en-Y gastric bypass (LRYGBP), matched for DM duration, type of DM treatment, and glycemic control. Results At 4-months after surgery, LSG and LRYGBP operated subjects lost a similar amount of weight (respectively, 20.6 ± 0.7% and 21.0 ± 0.6%). T2DM had resolved respectively in 51.4% and 62.0% of the LSG and LRYGBP operated subjects (P = 0.332). A shorter preoperative DM duration (P < 0.05), a preoperative DM treatment not including pharmacological agents, and a better pre-surgical fasting plasma glucose (P < 0.01) or HbA1c (P < 0.01), were significantly associated with a better type 2 DM outcome in both surgical groups. Conclusions Our data show that LSG and LRYGBP result in a similar rate of type 2 DM resolution at 4-months after surgery. Moreover, our data suggest that mechanisms beyond weight loss may be implicated in DM resolution following LSG and LRYGBP.     

腹腔镜袖状胃切除术治疗重度肥胖症的临床疗效

目的探讨腹腔镜下袖状胃切除术对重度肥胖症(体重指数BMI>35)的临床疗效。方法 2008年8月～2011年5月,对30例重度肥胖症患者实施腹腔镜袖状胃切除术,全身麻醉,腹腔镜下超声刀离断胃周韧带,术中电子胃镜指引下,使用Endo-GIA紧贴胃大弯侧行袖状胃切除。术后随访1年,观察BMI及超重体重下降百分比(excess weight loss,EWL%)的变化情况。结果 30例手术顺利,无术中并发症及中转开腹。术后1年体重指数(28.7±5.3)较术前(35.2±7.2)降低(t=3.98,P<0.001)。术后1年随访EWL%,根据Reinhold等制定的标准,效果极佳24例(80%)(EWL%76%～90%),良好6例(20%)(EWL%55%～73%)。结论腹腔镜袖状胃切除术治疗重度肥胖症近期疗效明显,长期疗效有待进一步观察。     

Nonsurgical Treatment of Staple Line Leaks after Laparoscopic Sleeve Gastrectomy

Background  Laparoscopic sleeve gastrectomy (LSG) is gaining popularity as a “per se” bariatric procedure due to its effectiveness on weight loss and comorbidity resolution. The most feared and life-threatening complication after LSG is the staple line leak and its management is still a debated issue. Aim of this paper is to analyze the incidence of leak and the treatment solutions adopted in a consecutive series of 200 LSG. Methods  From October 2002 to November 2008, 200 patients underwent LSG. Nineteen patients (9.5%) had a body mass index (BMI) of >60 kg/m². A 48-Fr bougie is used to obtain an 80–120-ml gastric pouch. An oversewing running suture to reinforce the staple line was performed in the last 100 cases. The technique adopted to reinforce the staple line is a running suture taken through and through the complete stomach wall. Results  Staple line leaks occurred in six patients (mean BMI 52.5; mean age 41.6 years). Leak presentation was early in three cases (first, second, and third postoperative (PO) day), late in the remaining three cases (11th, 22nd, and 30th PO day). The most common leak location was at the esophagogastric junction (five cases). Mortality was nihil. Nonoperative management (total parenteral nutrition, proton pump inhibitor, and antibiotics) was adopted in all cases. Percutaneous abdominal drainage was placed in five patients. In one case, a small fistula was successfully treated by endoscopic injection of fibrin glue only. Self-expandable covered stent was used in three cases. Complete healing of leaks was obtained in all patients (mean healing time 71 days). Conclusion  Nonoperative treatment (percutaneous drainage, endoscopy, stent) is feasible, safe, and effective for staple line leaks in patients undergoing LSG; furthermore, it may avoid more mutilating procedures such as total gastrectomy.     

Laparoscopic Sleeve Gastrectomy with Minimal Morbidity Early Results in 120 Morbidly Obese Patients

Background  In recent years, laparoscopic sleeve gastrectomy (LSG) as a single-stage procedure for the treatment of morbid obesity is becoming increasingly popular. Of continuing concern are the rate of postoperative complications and the lack of consensus as to surgical technique. Methods  A prospective study assessment was made of 120 consecutive morbidly obese patients with body mass index (BMI) of 43 ± 5 (30 to 63), who underwent LSG using the following technique: (1) division of the vascular supply of the greater gastric curvature and application of the linear stapler-cutter device beginning at 6–7 cm from the pylorus so that part of the antrum remains; (2) inversion of the staple line by placement of a seroserosal continuous suture close to the staple line; (3) use of a 48 Fr bougie so as to avoid possible stricture; (4) firing of the stapler parallel to the bougie to make the sleeve as narrow as possible and prevent segmental dilatation. Results  Intraoperative difficulties were encountered in four patients. There were no postoperative complications—no hemorrhage from the staple line, no anastomotic leakage or stricture, and no mortality. In 20 patients prior to the sleeve procedure, a gastric band was removed. During a median follow-up of 11.7 months (range 2–31 months), percent of excess BMI lost reached 53 ± 24% and the BMI decreased from 43 ± 5 to 34 ± 5 kg/m². Patient satisfaction scoring (1–4) at least 1 year after surgery was 3.6 ± 0.8. Conclusions  The good early results obtained with the above-outlined surgical technique in 120 consecutive patients undergoing LSG indicate that it is a safe and effective procedure for morbid obesity. However, long-term results are still pending.     

The “Tip-Stitch”: A Time-Saving Technique for Specimen Extraction in Sleeve Gastrectomy

Background  Laparoscopic sleeve gastrectomy has gained popularity as another tool available to weight loss surgeons, with published excess weight loss results similar or superior to laparoscopic adjustable gastric banding. The gastrectomy specimen consists of a hollow “bag” of fundus, which is typically extracted through an enlarged port site. Extraction can be a challenging and time-consuming portion of the operation. Methods  The “Tip-Stitch” is a low-technology method of orienting the gastric specimen for easy retrieval. A suture through the distal tip of the specimen allows for extraction without enlarging a 15-mm trocar site. Results  We report a small series of sleeve gastrectomy using this specimen extraction technique. No wound infections were seen, and enlargement of the fascial incision was done only once, early in our experience. Conclusions  Our technique describes a reliable method of intact specimen retrieval, typically without enlarging a 15-mm trocar incision. The opinions expressed on this document are solely those of the authors and do not represent an endorsement by or the views of the United States Air Force, the Department of Defense, or the United States Government.     

Treatment of Gastric Leaks with Coated Self-Expanding Stents after Sleeve Gastrectomy

Background Duodenal switch (DS) is one of the most effective techniques for the treatment of morbid obesity and its co-morbidities, with mortality rate <1%, but with 9.4% morbidity rates (6.5% due to leaks). In our experience, leaks of the staple-line after sleeve gastrectomy (SG) are the most frequent sites of fistula formation and conservative treatment usually takes a long time.We present our experience in the treatment of gastric leaks with coated self-expandable stents (CSES). Methods 6 patients had gastric leaks at the gastroesophageal (GE) junction after SG or DS. One patient had a symptomatic gastro-bronchial fistula. Stents were placed by the interventional radiologist under fluoroscopic control and removed endoscopically. In one case, we used an uncoated Wallstent. In two patients, percutaneous microcoil embolization of the fistula was added. Results The patient treated with the Wallstent required a total gastrectomy 6 months after placement of the uncovered stent. In the other 5 patients, coated stents were successfully removed and the gastric leaks completely sealed. Conclusions CSES are proposed as an alternative therapeutic option for the management of GE junction leaks in bariatric surgery with good results in terms of morbidity and survival.     

Laparoscopic adjustable gastric banding versus laparoscopic gastric bypass for morbid obesity: A single-institution comparison study of early results

Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic adjustable gastric banding (LAGB) are common surgical procedures for morbid obesity, but few studies have compared LRYGB and LAGB. All patients who underwent LRYGB and LAGB by a single surgeon at Legacy Health System were identified from a prospectively maintained database. Preoperatively, most patients were allowed to choose between LRYGB and LAGB. Age, sex, body mass index (BMI), complications, mortality, and weight loss were examined. From October 2000 to November 2003, 219 patients underwent LRYGB and 154 patients underwent LAGB. Mean preoperative BMI was 49.5 ± 6.6 and 50.9 ± 9.4 kg/m2, respectively (P = 0.10). Mean age was 42 ± 9 and 47 < 11 years (P < 0.001). The LAGB group had a higher proportion of male patients (21% versus 7%, P < 0.001). Patients undergoing LRYGB had longer operative times (134 versus 76 minutes, P < 0.001), more blood loss (43 versus 28 ml, P < 0.01), and longer hospital stays (2.6 versus 1.3 days, P < 0.001). Excess weight loss was 35% for LRYGB versus 19% for LAGB at 3-month follow-up (P < 0.001), 49% versus 25% at 6 months (P < 0.001), 64% versus 36% at 12 months (P < 0.001), 70% versus 45% at 24 months (P < 0.001), and 60% versus 57% at 36 months (P = 0.85). Major complications occurred in 7% and 6% (P < 0.58) and minor complications occurred in 18% and 20% (P = 0.65) of patients, respectively. Reoperation occurred in 21 patients (10%) after LRYGB and 31 (20%) patients after LAGB (P < 0.01). Of patients undergoing reoperation, eight (38%) LRYGB patients and one (3%) LAGB patient required open laparotomy. One death occurred in each group. Patients undergoing laparoscopic adjustable gastric banding have shorter operative times, less blood loss, and shorter hospital stays compared with laparoscopic gastric bypass patients. The incidence of major and minor complications is similar; however, morbidity after LRYGB is potentially greater and the reoperation rate is higher in the LAGB group. Early weight loss is greater with gastric bypass, but the difference appears to diminish over time. Presented at the Forty-Fifth Annual Meeting of The Society for Surgery of the Alimentary Tract, New Orleans, Louisiana, May 15–19, 2004 (oral presentation). Supported in part by an educational grant from U.S. Surgical (Norwalk, CT).     

Experience with Laparoscopic Adjustable Gastric Banding (La-Band System) up to 8 Years

Morbid obesity occurs in 2-5% of the population in Western countries.

Laparoscopic adjustable silicone gastric banding is a minimally invasive, adjustable and reversible procedure for the treatment of morbid obesity.

The lap-band system was evaluated retrospectively in a series of 222 patients. Postoperative outcome and weight loss patterns at up to 8 years follow-up are presented. The most frequent late complications were a leak between the port and the catheter, which occurred in 21 patients (9,4%) and total and irreversible food intolerance due to pouch dilation and/or slippage, which occurred in 13 patients (5,8%). The postoperative BMI reductions are successful and stable after a follow-up of up to 96 months. The lap-band system seems an effective procedure for achieving appreciable and stable weight loss up to 8 years of follow-up and the complications and re-operation rates are acceptable. In 81% of the cases also, the patient is very satisfied with the results of the operation. From the 47,3% who found their quality of life before the operation bad or even devastating, 93% envoy life after the operation like never before.     

The Second International Consensus Summit for Sleeve Gastrectomy, March 19–21, 2009

BackgroundSleeve gastrectomy (SG) is a rapid and comparatively simple bariatric operation, which thus far shows good resolution of co-morbidities and good weight loss. The potential peri-operative complications must be recognized and treated promptly. Like other bariatric operations, there are variations in technique. Laparoscopic SG was initially performed for high-risk patients to increase the safety of a second operation. However, indications for SG have been increasing. Interaction among those performing this procedure is necessary, and the Second International Consensus Summit for SG (ICSSG) was held to evaluate techniques and results.MethodsA questionnaire was filled out by attendees at the Second ICSSG, held March 19–22, 2009, in Miami Beach, and rapid responses were recorded during the consensus part.ResultsFindings are based on 106 questionnaires representing a total of 14,776 SGs. In 86.3%, SG was intended as the sole operation. A total of 81.9% of the surgeons reported no conversions from a laparoscopic to an open SG. Mean ± SD percent excess weight loss was as follows: 1 year, 60.7 ± 15.6; 2 years, 64.7 ± 12.9; 3 years, 61.7 ± 11.4; 4 years 64.6 ± 10.5; >4 years, 48.5 ± 8.7. Bougie size was 35.6F ± 4.9F (median 34.0F, range 16F–60F). The dissection commenced 5.0 ± 1.4 cm (median 5.0 cm, range 1–10 cm) proximal to the pylorus. Staple-line was reinforced by 65.1% of the responders; of these, 50.9% over-sew, 42.1% buttress, and 7% do both. Estimated percent of fundus removed was 95.8 ± 12%; many expressed caution to avoid involving the esophagus. Post-operatively, a high leak occurred in 1.5%, a lower leak in 0.5%, hemorrhage in 1.1%, splenic injury in 0.1%, and later stenosis in 0.9%. Post-operative gastroesophageal reflux (～3 mo) was reported in 6.5% (range 0–83%). Mortality was 0.2 ± 0.9% (total 30 deaths in 14,776 patients). During the consensus part, the audience responded that there was enough evidence published to support the use of SG as a primary procedure to treat morbid obesity and indicated that it is on par with adjustable gastric banding and Roux-en-Y gastric bypass, with a yes vote at 77%.ConclusionSG for morbid obesity is very promising as a primary operation.