Long-term outcomes of laparoscopic sleeve gastrectomy as a primary bariatric procedure

BackgroundLaparoscopic sleeve gastrectomy (LSG) has been established as a reliable bariatric procedure, but questions have emerged regarding its long-term results. Our aim is to report the long-term outcomes of LSG as a primary bariatric procedure.MethodsRetrospective analysis of patients submitted to LSG between 2005 and 2007 in our institution. Long-term outcomes at 5 years were analyzed in terms of body mass index (BMI), excess weight loss (EWL) and co-morbidities resolution. Surgical success was defined as %EWL>50%. Also, we compared long-term results according to preoperative BMI, using Mann-Whitney test.ResultsA total of 161 LSG were analyzed, and 114 patients (70.8%) were women. The median age was 36 years old (range 16–65), median preoperative BMI was 34.9 kg/m² (interquartile range [IQR], 33.3–37.5). A total of 112 patients (70%) completed 5 years of follow-up. At the fifth year, median BMI and %EWL was 28.5 kg/m² (IQR: 25.8–31.9) and 62.9% (IQR: 45.3–89.6), respectively, with a surgical success of 73.2% of followed patients. According to preoperative BMI, surgical success was achieved in 80% of patients with BMI<35 kg/m², 75% of BMI 35–40 kg/m², and 52.6% of BMI>40 kg/m², with significant lower %EWL in patients with BMI>40 kg/m² (P = .001 and .004). Dyslipidemia and insulin resistance resolution was 80.7% and 84.7%, respectively. A total of 26.7% of patients reported new-onset gastroesophageal reflux symptoms at 5 years.ConclusionLSG as a primary procedure is a reliable surgery. We observed positive long-term outcomes of %EWL and co-morbidities resolution. In our series, best results are seen in patients with preoperative BMI<40 kg/m².     

Outcomes of laparoscopic proximal gastrectomy with esophagojejunal reconstruction for chronic staple line disruption after laparoscopic sleeve gastrectomy

BackgroundSleeve gastrectomy is now a frequently performed bariatric procedure for severely obese patients and may have the lowest frequency of short-term or long-term complications. The aim of this study is to describe our experience in managing chronic proximal leaks with a proximal gastrectomy and Roux-en-Y esophagojejunostomy (PGEJ).MethodsA retrospective review was performed of all patients having proximal chronic staple-line disruptions (CSLD) after undergoing laparoscopic sleeve gastrectomy.ResultsFifteen patients had proximal CSLD and were treated with PGEJ. There was 1 (6.6%) releak in this group, which resolved with nonoperative treatment. Other postoperative morbidities in this series included partial small bowel obstruction (n = 1) and subhepatic bile collection (n = 1), both of which resolved without operative intervention.ConclusionPGEJ appears to be a safe and effective procedure for chronic staple-line disruptions after sleeve gastrectomy.     

轻、中度单纯性肥胖患者行袖状胃切除术的临床分析

目的探讨轻、中度单纯性肥胖(27.5 kg/m²≤体质量指数<32.5 kg/m²)患者行腹腔镜袖状胃切除(laparoscopic sleeve gastrectomy,LSG)术后的疗效及生存质量。 方法将2014年2月至2015年8月广州中医药大学金沙洲医院亚太减重暨糖尿病外科中心收治的术后随访满1年的33例行LSG术的轻、中度单纯性肥胖患者进行回顾性分析。观察其物理指标及生存质量。 结果术后1年,患者体质量下降明显,多余体质量减少百分比(percentage of excess weight loss,EWL%)为75.0%,术前术后的体质量、腰围、臀围及体质量指数比较,均差异有统计学意义(P<0.05)。术前术后患者OSF－36总评分比较,均差异有统计学意义(P<0.05)。 结论轻、中度单纯性肥胖患者行LSG术的近期减重效果确切,术后生存质量明显改善,远期减重效果及生存质量还需大样本、长期的随访。     

Porto-mesenteric vein thrombosis after laparoscopic sleeve gastrectomy. A case report

İntroduction and importancePorta-mesenteric vein thrombosis (PMVT) is a rare but fatal complication in patients who are undergoing bariatric surgery. In this report, we present a rare case of a PMVT after laparoscopic sleeve gastrectomy (LSG).Case presentationA 52-year-old male patient with a body mass index of 42 kg/m² was admitted to our clinic for morbid obesity. Standart LSG was performed with 5 trocar technique. 15 days after LSG, the patient admitted to the emergency department with complaints of abdominal pain, nausea and vomiting. The patient was dehydrated. His C-reactive protein level was 138 mg/L. Abdominal computerized tomography with contrast was performed and showed thickening of a part of small bowel wall in 10 cm length. Also, major trombosis were detected in the superior mesenteric vein branches and portal vein. The patient was hospitalized and 2 × 10,000 IU/1.0 mL high dosage low moleculer weight heparin (LMWH) therapy was initiated. The patient’s clinical signs recovered rapidly following treatment.Clinical discussionİn LSG, if the gastroepiploic venous arcus, which runs along the greater curvatura, and has a direct connection to the portal circulation is damaged, a local thrombus may form and move towards the portal system over time. Dehydration is another significant predisposing factor for PMVT. Some patients may develop life-threatening intestinal ischemia. Abdominal tomography with contrast plays a major role in diagnosis.ConclusionPMVT should be considered as a serious complication after LSG in patients with abdominal pain. With early diagnosis and anticoagulant therapy, patients’s clinical symptoms may improve quicly.     

Assessment of the procoagulant potential after laparoscopic sleeve gastrectomy: a potential role for extended thromboprophylaxis

Background

Bariatric surgery is associated with increased thromboembolic risk, which may extend well beyond hospital stay. The hemostatic mechanisms implicated in this risk are not well established.

Third International Summit: current status of sleeve gastrectomy

Background

Laparoscopic sleeve gastrectomy (LSG) has been performed for morbid obesity in the past 10 years. LSG was originally intended as a first-stage procedure in high-risk patients but has become a stand-alone operation for many bariatric surgeons. Ongoing review is necessary regarding the durability of the weight loss, complications, and need for second-stage operations.

Methods

The first International Summit for LSG was held in October 2007, the second in March 2009, and this third in December 2010. There were presentations by experts, and, to provide a consensus, a questionnaire was completed by 88 attendees who had >1 year (mean 3.6 ± 1.5, range 1–8) of experience with LSG.

Results

The results of the questionnaire were based on 19,605 LSGs performed within 3.6 ± 1.5 years (228.8 ± 275.0 LSGs/surgeon). LSG had been intended as the sole operation in 86.4% of the cases; in these, a second-second stage became necessary in 2.2%. LSG was completed laparoscopically in 99.7% of the cases. The mean percentage of excess weight loss at 1, 2, 3, 4, and 5 years was 62.7%, 64.7%, 64.0%, 57.3%, and 60.0%, respectively. The bougie size was 28–60F (mean 36F, 70% blunt tip). Resection began 1.5–7.0 cm (mean 4.8) proximal to the pylorus. Of the surgeons, 67.1% reinforced the staple line, 57% with buttress material and 43% with oversewing. The respondents excised an estimated 92.9% ± 8.0% (median 95.0%) of fundus (i.e., a tiny portion is maintained lateral to the angle of His). A drain is left by 57.6%, usually closed suction. High leaks occurred in 1.3% of cases (range 0–10%); lower leaks occurred in .5%. Intraluminal bleeding occurred in 2.0% of cases. The mortality rate was .1% ± .3%.

Conclusion

According to the questionnaire, presentations, and debates, the weight loss and improvement in diabetes appear to be better than with laparoscopic adjustable gastric banding and on par with Roux-en-Y gastric bypass. High leaks are infrequent but problematic.     

Laparoscopic sleeve gastrectomy with Rossetti fundoplication: long-term (5-year) follow-up

BackgroundGastroesophageal reflux disease (GERD), including erosive esophagitis, is highly prevalent in the obese population. Barrett’s esophagus is the consequence of untreated GERD. Laparoscopic sleeve gastrectomy is one of the most frequently performed bariatric procedures. This study presents results after 5 years of follow-up of combined LSG and Rossetti fundoplication for the treatment of GERD, esophagitis, and Barrett’s esophagus in patients with morbid obesity.ObjectiveTo evaluate long-term results after sleeve gastrectomy with Rossetti fundoplication.SettingPublic university hospital in Italy.MethodsSince January 2015, more than 450 patients with obesity underwent sleeve gastrectomy with a Rossetti fundoplication procedure as part of prospective studies underway at our center performed by 4 different expert bariatric surgeons. Currently, 127 patients have a follow-up of 5 years or more.ResultsMean patient age was 42.9 ± 10.3 years, and mean body mass index was 42.4 ± 6.1 kg/m². In total, 74.8% of patients were experiencing GERD before surgery. In 29 of 127 patients (22.8%), preoperative gastroscopy showed signs of esophagitis and/or Barrett’s esophagus. In particular, 23 of 127 patients (18.1%) had grade A esophagitis, 2 of 127 (1.6%) had grade B, 2 of 127 (1.6%) had grade C, and 2 of 127 (1.6%) had Barrett’s esophagus. Mean operative time was 51 ± 21 minutes. No intraoperative complications or conversions were reported. A regular postoperative course was seen in 91.3% of patients. Sixty months after surgery, more than 95% of patients did not experience any reflux symptoms. Percent total weight loss at follow-up was comparable with that with sleeve gastrectomy. Endoscopic follow-up demonstrated improvement of esophagitis lesions (including Barrett’s esophagus) present in the preoperative setting.ConclusionLaparoscopic sleeve gastrectomy with Rossetti fundoplication is well tolerated, feasible, and safe in patients with obesity, providing adequate weight loss results and complete resolution of clinical signs of GERD. We have recorded an improvement in esophagitis lesions present at preoperative gastroscopy and complete resolution of Barrett’s esophagus within 5 years of follow-up.     

Resleeve for failed laparoscopic sleeve gastrectomy: systematic review and meta-analysis

Despite excellent long-term results, insufficient weight loss, weight regain, and pathologic gastroesophageal reflux disease may require revisional procedures after laparoscopic sleeve gastrectomy (LSG). Resleeve gastrectomy (ReSG) for failed LSG, has been proposed as an alternative to more complex malabsorptive procedures. The aim of this systematic review and meta-analysis was to examine the current evidence on the therapeutic role and outcomes of ReSG for failed LSG. PubMed, EMBASE, and Web of Science data sets were consulted. A systematic review and Frequentist meta-analysis were performed. Ten studies published between 2010 and 2019 met the inclusion criteria for a total of 300 patients. The age of the patient population ranged from 20 to 66 years old and 80.5% were females. The elapsed time between the LSG and ReSG ranged from 9 to 132 months. The estimated pooled prevalence of postoperative leak and overall complications were 2.0% (95% confidence interval [CI] = .5%–4.7%) and 7.6% (95%CI = 3.1%–13.4%). The estimated pooled mean operative time and hospital length of stay were 51 minutes (95%CI = 49.4–52.6) and 3.3 days (95%CI = 3.13–3.51). The postoperative follow-up ranged from 12 to 36 months and the estimated pooled mean percentage excess weight loss was 61.46% (95%CI = 55.9–66.9). The overall mortality ranged from 0% to 2.2%. ReSG after failed LSG seems feasible and safe with acceptable postoperative leak rate, overall complications, and mortality. The effectiveness of ReSG in term of weight loss seems promising in the short-term but further studies are warranted to explore its effect on patients’ quality of life, postoperative gastroesophageal reflux disease, and long-term weight loss.     

腹腔镜袖状胃切除术的围手术期处理

目的总结腹腔镜袖状胃切除术（LSG）治疗病态性肥胖症患者的疗效及其围手术期处理方法。方法回顾性分析2010年5月至2012年12月在第二军医大学长海医院行LsG手术、并获得至少1年术后随访的57例病态性肥胖症患者的临床资料。所有患者均予以充分的术前准备和严格的术后管理．并通过随访了解其术后额外体质量减轻百分率（EWL％）和术前合并症的缓解情况。结果除1例因腹腔广泛粘连中转开腹,其余56例患者均在腹腔镜下完成手术。手术时间（102．0±15．2）min,术中出血（132．3±45．6）ml。无围手术期死亡患者,无吻合口瘘、吻合口狭窄及切口感染发生。术后出血2例。其中1例经输血和止血药等保守治疗止血,另1例行再次腹腔镜探查止血。全组患者术后3、6和12月,EWL％分别为（54．9±13．8）％、（79．0±23．6）％和（106．9±25．1）％,且术前合并症均获得了不同程度的缓解或改善。结论LSG对肥胖症有良好的临床治疗效果,通过加强围手术期管理．可以提高手术安全性和术后疗效。     

Cross-sectional review of effects of laparoscopic sleeve gastrectomy at 1, 3, and 5 years

Background

Laparoscopic sleeve gastrectomy evolved as a primary bariatric procedure without data on longer term outcomes. Our objective was to measure the weight changes and quality of life after laparoscopic sleeve gastrectomy at a university hospital.

Methods

The patients scheduled follow-up visits for clinical measurements, blood sampling, and form completion, including the Medical Outcomes Study 36-item short-form questionnaire, the Impact of Weight on the Quality of Life-Lite questionnaire, and Beck depression inventory. Comparisons were performed among patients with a follow-up of 1, 3, and 5 years after laparoscopic sleeve gastrectomy.

Results

A total of 77 patients (35 at 1, 19 at 3, and 23 at 5 yr) were similar in gender (70.1% women), percentage of body fat, and body mass index by analysis of variance (P = .12; 1 versus 3 yr, P = .04). The 5-year group was older (P = .07). The 3 groups were different in the percentage of excess body mass index loss (P = .04). Differences in the Beck depression inventory were not significant by analysis of variance but were for 1 year versus 5 years (P = .04). For the Impact of Weight on the Quality of Life-Lite total scores, the difference was significant (P = .06; 1 versus 5 yr, P = .027; and public distress subscore at 1 and 5 yr, P = .04). The differences in the other domains were not significant. For the Medical Outcomes Study 36-item short-form, differences in the physical differences domain was significant (P = .001). The differences in physical function, social function, general health, vitality, body pain, and role physical were significant. The differences in mental health and role emotional were not. The differences in the Beck depression inventory scores were not significant using analysis of variance but were between the 1-year and 5-year scores (P = .04).

Conclusion

Patients undergoing laparoscopic sleeve gastrectomy had a similar body mass index at 1, 3, and 5 years. However, the percentage of excess body mass index loss was different. No differences were found in the percentage of body fat. The health-related quality of life scores resembled community norms, although the physical health differences in the 3 groups were significant, The Beck depression inventory scores were elevated at 5 years compared with at 1 year.     

Review of long-term weight loss results after laparoscopic sleeve gastrectomy

Sleeve gastrectomy (SG) has gained enormous popularity both as a first-stage procedure in high-risk super-obese patients and as a stand-alone procedure. The objective of this study was to evaluate the long-term weight loss results after SG published in the literature and compare them with the well-documented short-term and mid-term weight loss results. A detailed search in PubMed using the keywords “sleeve gastrectomy” and “long-term results” found 16 studies fulfilling the criteria of this study. A total of 492 patients were analyzed, with a follow-up of at least 5 years after laparoscopic sleeve gastrectomy (LSG) (373 at 5 years, 72 at 6 years, 13 at 7 years, and 34 at 8 or more years). Of the total number of patients, 71.1% were women (15 studies, n = 432 patients). Mean patient age was 45.1 years (15 studies, n = 432 patients). Mean preoperative body mass index in all 16 studies was 49.2 kg/m². The mean percentage excess weight loss (%EWL) was 62.3%, 53.8%, 43%, and 54.8% at 5, 6, 7, and 8 or more years after LSG, respectively. The overall mean %EWL (defined as the average %EWL at 5 or more years after LSG) was 59.3% (12 studies, n = 377 patients). The overall attrition rate was 31.2% (13 studies). LSG seems to maintain its well-documented weight loss outcome at 5 or more years postoperatively, with the overall mean %EWL at 5 or more years after LSG still remaining>50%. The existing data support the role of LSG in the treatment of morbid obesity.     

腹腔镜胃袖状切除术近期并发症与处理对策

腹腔镜胃袖状切除术由于技术相对简单、安全，并具有很好地减重与改善代谢效果，成为目前最常见的减重手术术式。美国胃袖状切除占所有减重手术方式的61.4%，而国内该手术比例高达95%。该手术最常见的近期并发症包括胃漏、出血及术后呕吐。目前减重手术在全国范围内逐渐普遍开展，充分认识及很好地处理这些并发症，注重细节、规范操作，对于做好腹腔镜胃袖状切除术，避免手术并发症发生，保证手术安全具有重要意义。     

三孔法在腹腔镜胃袖状切除术中的应用

目的: 初步探讨三孔法腹腔镜胃袖状切除术（three-port laparoscopic sleeve gastrectomy, TPLSG）的可行性、安全性及短期临床疗效。方法: 回顾性分析我院普外科2018年1月至7月接受腹腔镜胃袖状切除术（laparoscopic sleeve gastrectomy, LSG）的病人共39例,其中20例为TPLSG,19例常规五孔LSG。比较两种手术方式的手术时间、术中出血量、手术相关并发症发生率、术后疼痛程度、术后住院时间以及术后3个月多余体重减少率（excess weight loss, %EWL）。结果: TPLSG组术后疼痛程度和术后出院时间均少于常规五孔LSG组,差异有统计学意义（P<0.05）,两组的手术时间、术中出血量、手术相关并发症发生率、术后3个月%EWL的差异均无统计学意义（P>0.05）。结论: TPLSG是一种安全有效的手术方式,其临床效果安全有效,可加快病人康复,缩短住院时间。     

Routine upper gastrointestinal swallow studies after laparoscopic sleeve gastrectomy are unnecessary

Background

Laparoscopic sleeve gastrectomy has gained popularity among bariatric surgeons. The purpose of this study was to evaluate the usefulness of early upper gastrointestinal (UGI) contrast studies in the detection of postoperative complications.

Methods

Radiographic reports were reviewed from April 2006 to January 2013. During that time, 161 patients underwent laparoscopic sleeve gastrectomy. All patients were submitted to UGI examination on postoperative day (POD) 1.

Results

Among the 161 patients who underwent UGI, no contrast leaks were found on POD 1. Three patients (1.9%) developed stapler line leaks near the gastroesophageal junction, which were diagnosed on PODs 3, 4, and 10. Gastroesophageal reflux in 5 patients (3.1%) and delayed gastroesophageal transit in 10 patients (6.2%) were detected.

Conclusions

The results of this study show that UGI series on POD 1 cannot assess the integrity of the gastric remnant. Early UGI series are not required as routine procedures in all operated patients. Computed tomographic swallow studies should be performed in patients who postoperatively develop clinical signs and symptoms of complications such as tachycardia, pain, or fever.     

Effects of laparoscopic sleeve gastrectomy on attentional processing of food-related information: Evidence from eye-tracking

BackgroundWeight loss after laparoscopic sleeve gastrectomy (LSG) might be associated partially with changes in reward system functioning and altered appetitive responses to food cues. Food cue processing refers to motivational, affective, and cognitive responses to stimuli that are associated with food. We investigated if food cue processing is altered 6 months after weight loss that is induced by LSG. We expected patients after LSG to show reduced appetitive responses to food cues.MethodsIn an experimental longitudinal exploratory study, 17 severely obese patients (body mass index [BMI]: 48.3±6.5 kg/m²) were investigated presurgery and 6 months postsurgery. We used eye-tracking to assess attentional biases during free viewing of food versus nonfood cues, assessed pleasantness ratings of food cues, and self-reported food craving.ResultsAfter LSG, the mean BMI of patients was 36.4±6.0 kg/m², and the percentage of excess weight loss (%EWL) was 46.6%±14.0%. Six months after LSG, patients showed an attentional bias toward nonfood cues compared with presurgery, reported lower food craving, and rated presented food stimuli as less pleasant.ConclusionEvidence of altered food cue processing was found in patients after LSG, which may be interpreted as reduced food reward associated with increased cognitive control. Surgery-induced physiologic, cognitive-motivational, and behavioral changes may lead to a desensitization of the reward system and enhanced cognitive control.     

Comparison of laparoscopic sleeve gastrectomy leak rates in four staple-line reinforcement options: a systematic review

ObjectiveThe study compared laparoscopic sleeve gastrectomy (LSG) staple-line leak rates of 4 prevalent surgical options: no reinforcement, oversewing, nonabsorbable bovine pericardial strips (BPS), and absorbable polymer membrane (APM).BackgroundLSG is a multipurpose bariatric/metabolic procedure with effectiveness proven through the intermediate term. Staple-line leak is a severe complication of LSG for which no definitive method of prevention has been identified.MethodsThe systematic review study design was employed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement screening guidelines. Inclusion criteria centered on variables potentially relevant to LSG leak: leak rate, age, gender, calibrating bougie size, distance between pylorus and gastric transection line, overall complication rate, and mortality. Analysis of variance models were used to explore differences in select demographic and surgical technique variables characterizing each reinforcement group. An omnibus χ² test followed by independent Fisher’s exact tests were used to compare leak rates.ResultsThere were 659 articles identified; 41 duplicates removed. Of 618 remaining articles, 324 did not meet inclusion criteria. Of the 294 remaining articles, 206 were eliminated (kin studies, those not reporting staple-line or leak incidence, those reporting discontinued products). There were 88 papers included in the analysis. Statistically significant differences were found between groups across demographic and surgical variables studied (p<0.001). There were 191 leaks in 8,920 patients; overall leak rate 2.1%. Leak rates ranged from 1.09% (APM) to 3.3% (BPS); APM leak rate was significantly lower than other groups (p< 0.05).ConclusionSystematic review of 88 included studies representing 8,920 patients found that the leak rate in LSG was significantly lower using APM staple-line reinforcement than oversewing, BPS reinforcement, or no reinforcement.     

Laparoscopic re-sleeve gastrectomy as a treatment of weight regain after sleeve gastrectomy

AIM: To evaluate laparoscopic re-sleeve gastrectomy as a treatment of weight regain after Sleeve.METHODS: Laparoscopic sleeve gastrectomy is a com-mon bariatric procedure. Weight regain after long-term follow-up is reported. Patients were considered for laparoscopic re-sleeve gastrectomy when we observed progressive weight regain and persistence of comorbid-ities associated with evidence of dilated gastric fundus and/or antrum on upper gastro-intestinal series. Follow-up visits were scheduled at 1, 3, 6 and 12 mo after surgery and every 6 mo thereafter. Measures of change from baseline at different times were analyzed with the paired samples t test. RESULTS: We observed progressive weight regain after sleeve in 11 of the 201 patients(5.4%) who had a mean follow-up of 21.1 ± 9.7 mo(range 6-57 mo). Three patients started to regain weight after 6 mo fol-lowing Sleeve, 5 patients after 12 mo, 3 patients after 18 m. Re-sleeve gastrectomy was always performed by laparoscopy. The mean time of intervention was 55.8 ± 29.1 min. In all cases, neither intra-operative nor post-operative complications occurred. After 1 year follow-up we observed a significant(P 0.05) mean body mass index reduction(-6.6 ± 2.7 kg/m2) and mean % ex-cess weight loss(%EWL) increase(+31.0% ± 15.8%). An important reduction of antihypertensive drugs and hypoglycemic agents was observed after re-sleeve in those patients affected by hypertension and diabetes. Joint problems and sleep apnea syndrome improved in all 11 patients.CONCLUSION: Laparoscopic re-sleeve gastrectomy is a feasible and effective intervention to correct weight regain after sleeve.     

Sleeve gastrectomy to aortic valve replacement: safe?

BackgroundBariatric surgery has favorable results on cardiac structure and function, but there is minimal research on its utility in the cardiac comorbid population.ObjectivesTo determine if laparoscopic sleeve gastrectomy (SG) is safe in patients with symptomatic aortic stenosis (AS).SettingCommunity hospital/bariatric center of excellence in Pennsylvania.MethodsRetrospective single center review of 18 patients with morbid obesity and clinically significant AS. All SGs were performed between June 2016 and June 2020. Outcomes including hospital length of stay, 30-day readmission, and 30-day mortality in the study population (n = 18) were compared with 100 patients without AS who underwent SG at the same institution during the same time.ResultsThere were no perioperative deaths. Mean hospital stay in the study group was 1.78 days compared with 1.3 days in the noncardiac group (P = .1154). Two of 18 patients (11.1%) required readmission within 30 days, both for clinically significant bleeding, compared with 2 of 100 noncardiac patients (2.0%) (P = .1097). Seventeen of 18 study patients went on to have definitive aortic valve replacement surgery.ConclusionSG appears safe in patients with clinically significant AS. Although the AS group did have a higher rate of complications, these were manageable and did not increase mortality or LOS. Further studies are required to determine if outcomes of definitive aortic valve replacement are improved after bariatric surgery.