Complications After Sleeve Gastrectomy for Morbid Obesity

Background  Laparoscopic sleeve gastrectomy (LSG) is an increasingly used bariatric surgical procedure. Methods  We report our complications after LSG and compared to 17 other published LSG series. The individual types of complications for the published series were evaluated, with sample size calculations being performed to determine the number of patients required for a study that would detect halving the odds of the most common complications. Results  Of 53 patients who underwent LSG, 42 were women. Mean age was 51 years with a mean initial body mass index of 53.5 kg/m² and mean of eight comorbidities. Mean excess weight loss was 52.2% at 12 months and 59.2% at 18 months. No patients died. Five patients (9.4%) developed complications which included two staple line leaks that required reoperations, one preceded by a salmonella infection associated with vomiting, the other by postoperative pneumonia associated with coughing. Of the three staple line hemorrhages, one required hospitalization. The median complication rate for the 17 articles was 4.5%. With the number of patients for each series taken into account, the current series had a complication rate of 1.24 (95% CI 0.45–2.87) times that of the 17 published series. Published LSG complications were diverse, with the most common being reoperation, occurring after 3.6% of procedures. A study designed to detect halving the odds of reoperation would require more than 3,000 procedures. Conclusion  LSG is a safe procedure with low morbidity. Because leaks and reoperation in this series were preceded by large increments in intraabdominal pressure, attention to staple line reinforcements that increase burst pressure may be warranted. Paper presented at the North Texas ACS meeting in Dallas on February 21, 2008. Received award as best paper in GI surgery.     

Improvement of Hypothyroidism after Laparoscopic Roux-en-Y Gastric Bypass for Morbid Obesity

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) has been very effective in managing a broad range of morbid obesity-related co-morbidities. We report a beneficial effect of LRYGBP that has not been previously observed. Methods: Between December 1999 and September 2002, 224 patients underwent LRYGBP. Preoperative assessment for hypothyroidism and follow-up data were prospectively collected in our database. Improved thyroid function (ITF) or unchanged thyroid function (UTF) was determined by comparison of preoperative and postoperative thyroxine requirements. Results: 23 of 224 patients (10.3%) were treated preoperatively for hypothyroidism. During a median follow-up of 17 months, hypothyroidism was improved in 10/23 patients (43.5%). 2 patients had complete resolution, and the remaining 8 had reduction (14%-50%) of their thyroxine requirements. ITF occurred at a mean follow-up of 8.9 months and at a mean excess weight loss (EWL) of 57%. 6 of the 8 patients (75%) with ITF ≥ 25% had EWL >90% at last follow-up, compared to 1 out of 15 patients (6.6%) with UTF or <25% improvement (P =0.001). Comparison of patients with ITF and UTF over time during a 20-month follow-up, showed no significant difference in mean body mass index (BMI) and mean percentage of EWL. Conclusion: Improvement of hypothyroidism may be an additional benefit of bariatric surgery that has not been previously reported. Reduction of thyroxine requirements is most likely the result of the decrease in the BMI.     

A Meta-analysis of 2-Year Effect After Surgery: Laparoscopic Roux-en-Y Gastric Bypass Versus Laparoscopic Sleeve Gastrectomy for Morbid Obesity and Diabetes Mellitus

Literature search was performed for bariatric surgery from inception to September 2013, in which the effects of laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) on body mass index (BMI), percentage of excess weight loss (EWL%), and diabetes mellitus (DM) were compared 2 years post-surgery. A total of 9,756 cases of bariatric surgery from 16 studies were analyzed. Patients receiving LRYGB had significantly lower BMI and higher EWL% compared with those receiving LSG (BMI mean difference (MD)?=??1.38, 95 % confidence interval (CI)?=??1.72 to ?1.03; EWL% MD?=?5.06, 95 % CI?=?0.24 to 9.89). Improvement rate of DM was of no difference between the two types of bariatric surgeries (RR?=?1.05, 95 % CI?=?0.90 to 1.23). LRYGB had better long-term effect on body weight, while both LRYGB and LSG showed similar effects on DM.     

Sleeve Gastrectomy for Morbid Obesity

The rising prevalence of morbid obesity and the increased incidence of super-obese patients (BMI >50 kg/m2) seeking surgical treatments has led to the search for surgical techniques that provide adequate EWL with the least possible morbidity. Sleeve gastrectomy (SG) was initially added as a modification to the biliopancreatic diversion (BPD) and then combined with a duodenal switch (DS) in 1988. It was first performed laparoscopically in 1999 as part of a DS and subsequently done alone as a staged procedure in 2000. With the revelation that patients experienced weight loss after SG, interest in using this procedure as a bridge to more definitive surgical treatment has risen. Benefits of SG include the low rate of complications, the avoidance of foreign material, the maintenance of normal gastro-intestinal continuity, the absence of malabsorption and the ability to convert to multiple other operations. Reduction of the ghrelin-producing stomach mass may account for its superiority to other gastric restrictive procedures. SG should be in the armamentarium of all bariatric surgeons. Nonetheless, long-term studies are necessary to see if it is a durable procedure in the treatment of morbid obesity.     

Diagnosis and Management of Gastric Leaks After Laparoscopic Sleeve Gastrectomy for Morbid Obesity

Background  

Laparoscopic sleeve gastrectomy (LSG) is increasingly being recognised as a valid stand-alone procedure for the surgical management of morbid obesity. The leak rate from the gastric staple line ranges from 1.4% to 20%. From our experience of management of LSG leaks, we have been able to formulate an algorithm-based approach to the management of these patients.     

Conversion of Sleeve Gastrectomy to Roux-en-Y Gastric Bypass

Introduction

A subset of patients undergoing laparoscopic sleeve gastrectomy (SG) require eventual conversion to Roux-en-Y gastric bypass (RYGB) due to complications from SG or to enhance weight loss. The aim of this study is to characterize the indications for conversion and perioperative outcomes in a large cohort of these patients at a single institution.

Methods

Patients who underwent revisional surgery to convert SG to RYGB at our institution from January 2008 through January 2017 were retrospectively reviewed.

Results

Eighty-nine patients with previous SG underwent conversion to RYGB as part of a planned two-stage approach to gastric bypass (n?=?36), for weight recidivism (n?=?11), or for complications related to SG (n?=?42). Complications from SG that warranted conversion included refractory GERD (40.5%), sleeve stenosis (31.0%), gastrocutaneous (16.7%), or gastropleural (7.1%) fistula, and gastric torsion (4.1%). The mean (SD) age was 47.2 years (11.4 years) and median BMI at the time of revision was 43.2 kg/m². A laparoscopic approach was successfully completed in 76 patients (85.4%), with an additional of four completed robotically (4.5%). The median length of stay was 3 days. Twenty-eight patients (31.5%) had complications which included surgical site infection (20.2%), re-operation (6.7%), anastomotic stricture (3.4%), and one pulmonary embolism. There were no mortalities with a median follow-up of 15 months.

Conclusions

Conversion of SG to RYGB is safe and technically feasible when performed for complications of SG or to enhance weight loss. This operation can be successfully performed laparoscopically with a low rate of conversion and reasonable complication profile.

     

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.     

Internal Hernia after Laparoscopic Roux-en-Y Gastric Bypass for Morbid Obesity

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) is associated with a relatively high incidence of internal hernias (IH) when compared to the open operation. Methods: A search in PubMed MEDLINE from January 1994 through January 2006 was performed (keywords: obesity, laparoscopy, gastric bypass and internal hernia). Results: 26 studies with a total of 11,918 patients were considered. 300 cases of IH occurred (rate 2.51%). IH occurred 116 times at the level of the transverse colon mesentery (69%), 30 at the Petersen's space (18%), and 22 at the entero-enterostomy site (13%). 142 re-operations were performed laparoscopically (85.6%), and 24 by laparotomy (14.4%). Bowel resection was done in 5 cases (4.7%). Mortality was 1.17%. Conclusions: IH after LRYGBP has an incidence of 2.51%. Closure of mesenteric defects with non-absorbable running suture and antecolic Roux limb are recommended. Surgical exploration for suspicion of IH after LRYGBP should be first done by laparoscopy.     

Surgical Management of Gastro–Gastric Fistula After Divided Laparoscopic Roux-en-Y Gastric Bypass for Morbid Obesity

Background Gastro–gastric fistula (GGF) formation is uncommon after divided laparoscopic Roux-en-Y gastric bypass (LRYGB) for morbid obesity. Optimal surgical management remains controversial. Methods A retrospective review was performed of a prospectively maintained database of patients undergoing LRYGB from January 2001 to October 2006. Results Of 1,763 primary procedures, 27 patients (1.5%) developed a GGF and 10 (37%) resolved with medical management, whereas 17 (63%) required surgical intervention. An additional seven patients requiring surgical intervention for GGF after RYGB were referred from another institution. Indications for surgery included weight regain, recurrent, or non-healing gastrojejunal anastomotic (GJA) ulceration with persistent abdominal pain and/or hemorrhage, and/or recurrent GJA stricture. Remnant gastrectomy with GGF excision or exclusion was performed in 23 patients (96%) with an average in-hospital stay of 7.5 days (range, 3–27). Morbidity in six patients (25%) was caused by pneumonia, n = 2; wound infection, n = 2; staple-line bleed, n = 1; and subcapsular splenic hematoma, n = 1. There were no mortalities. Complete resolution of symptoms and associated ulceration was seen in the majority of patients. Conclusion Although uncommon, GGF formation can complicate divided LRYGB. Laparoscopic remnant gastrectomy with fistula excision or exclusion can be used to effectively manage symptomatic patients who fail to respond to conservative measures. This paper was presented at the SSAT Poster Presentation session on May 21st 2007 at the SSAT Annual Meeting at Digestive Disease Week, Washington (poster ID M1590).     

Retrograde Intussusception After Roux-En-Y Gastric Bypass for Morbid Obesity

Intussusception after Roux-en-Y gastric bypass procedure (RYGBP) is a rare complication that typically presents late after open or laparoscopic procedures with intermittent partial or complete bowel obstruction. It may be antegrade (peristaltic) or retrograde (antiperistaltic) and usually the common channel is affected. We describe an unusual case of retrograde intussusception that occurred 2 years after a laparoscopic RYGBP in which the proximal common channel had invaginated into the distal anastomotic site and the distal Roux limb.     

One-Anastomosis Gastric Bypass Versus Roux-en-Y Gastric Bypass as Revisional Surgery After Sleeve Gastrectomy: a Systematic Review and Meta-analysis

The demand for revisional bariatric surgery after sleeve gastrectomy (SG) has increased, but the ideal procedure remains unclear. A systematic review and meta-analysis were performed to compare the outcomes of weight loss and safety of one-anastomosis gastric bypass (OAGB) and Roux-en-Y gastric bypass (RYGB) as revisional procedures for failed SG. Four retrospective comparative studies were included, comprising 499 individuals. Patients submitted to OAGB had a more significant total weight loss (TWL) (MD =  − 5.89%; 95% CI − 6.80 to − 4.97) after revisional surgery. Overall early complication rate was similar between procedures (RD = 0.04; 95% CI: − 0.05 to 0.12). Limited and heterogeneous data prevent meaningful conclusions, but the present analysis suggests that OAGB has a better TWL after revisional surgery.

Graphical abstract

     

Comparison of Nutritional Status During the First Year After Sleeve Gastrectomy and Roux-en-Y Gastric Bypass

Sleeve gastrectomy (SG) is supposed to induce fewer nutritional deficiencies than gastric bypass (GBP). However, few studies have compared nutritional status after these two procedures, and the difference in weight loss (WL) between procedures may alter the results. Thus, our aim was to compare nutritional status after SG and GBP in subjects matched for postoperative weight. Forty-three subjects who underwent SG were matched for age, gender, and 6-month postoperative weight with 43 subjects who underwent GBP. Dietary intakes (DI), metabolic (MP), and nutritional parameters (NP) were recorded before and at 6 and 12 months after both procedures. Multivitamin supplements were systematically prescribed after surgery. Before surgery, BMI, DI, MP, and NP were similar between both groups. After surgery, LDL cholesterol, serum prealbumin, vitamin B12, urinary calcium, and vitamin D concentrations were lower after GBP than after SG, whereas WL and DI were similar after both procedures. However, the total number of deficiencies did not increase after surgery regardless of the procedure. In addition, we found a significant increase in liver enzymes and a greater decrease in C-reactive protein after GBP. In conclusion, during the first year after surgery, in patients with the same WL and following the same strategy of vitamin supplementation, global nutritional status was only slightly impaired after SG and GBP. However, some nutritional parameters were specifically altered after GBP, which could be related to malabsorption or other mechanisms, such as alterations in liver metabolism.     

Laparoscopic Gastric Bypass Versus Laparoscopic Sleeve Gastrectomy as a Definitive Surgical Procedure for Morbid Obesity. Mid-Term Results

Background

Laparoscopic sleeve gastrectomy (LSG) has been gaining acceptance because it has shown good short- and mid-term results as a single procedure for morbid obesity. The aim of this study was to compare short- and mid-term results between laparoscopic Roux-en-Y gastric bypass (LRYGB) and LSG.

Methods

Observational retrospective study from a prospective database of patients undergoing LRYGB and LSG between 2004 and 2011, where 249 patients (mean age 44.7 years) were included. Patients were followed at 1, 3, 6, 12, and 18 months, and annually thereafter. Short- and mid-term weight loss, comorbidity improvement or resolution, postoperative complications, re-interventions, and mortality were evaluated.

Results

One hundred thirty-five LRYGB and 114 LSG were included. Significant statistical differences between LRYGB and LSG were found in operative time (153 vs. 93 min. p?<?0.001), minor postoperative complications (21.5 % vs. 4.4 %, p?=?0.005), blood transfusions (8.8 % vs. 1.7 %, p?=?0.015), and length of hospital stay (4 vs. 3 days, p?<?0.001). There were no differences regarding major complications and re-interventions. There was no surgery-related mortality. The percentage of excess weight loss up to 4 years was similar in both groups (66?±?13.7 vs. 65?±?14.9 %). Both techniques showed similar results in comorbidities improvement or resolution at 1 year.

Conclusions

There is a similar short- and mid-term weight loss and 1-year comorbidity improvement or resolution between LRYGB and LSG, although minor complication rate is higher for LRYGB. Results of LSG as a single procedure need to be confirmed after a long-term follow-up.     

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。     

A Randomized Clinical Trial of Laparoscopic Roux-en-Y Gastric Bypass and Sleeve Gastrectomy for the Treatment of Morbid Obesity in China: a 5-Year Outcome

Background

No randomized comparative trials have presented long-term outcomes for laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB). The present study was designed to compare the efficacy and safety of these two procedures.

Methods

From January 2007 to July 2008, 64 eligible patients were randomly assigned to LSG or LRYGB. During the 5-year follow-up, we compared morbidity rate, body mass index (BMI), percent of excess weight loss (%EWL), Moorehead-Ardelt (M-A) II quality of life, and resolution or improvement rate of obesity-related comorbidities between the groups.

Results

Both groups were matched with respect to age, gender, and BMI. Slightly more major complications were observed in patients undergoing LRYGB (P?>?0.05). Weight loss was significantly better with LRYGB except during the first postoperative year. At 5 years, %EWL for LSG and LRYGB was 63.2?±?24.5 % and 76.2?±?21.7 % (P?=?0.02), respectively. No statistical difference was observed in quality of life between the groups at all intervals (P?>?0.05). At the last follow-up, most comorbidities in both groups were resolved or improved, with no difference between the groups (P?>?0.05).

Conclusion

LRYGB and LSG are equally safe and effective in quality of life and improvement or resolution of comorbidities, and LRYGB possesses the superiority in terms of weight loss. Further studies are needed to evaluate micronutrient deficiencies of these procedures.     

Superior Mesenteric Artery Syndrome after Laparoscopic Roux-en-Y Gastric Bypass for Morbid Obesity

Gastrointestinal obstructive complications after laparoscopic Roux-en-Y gastric bypass (LRYGBP) are not uncommon. Their usual causes are strictures, internal hernias and adhesions. Superior mesenteric artery (SMA) syndrome is a rare disorder caused by compression of the third portion of the duodenum by the SMA that can occur after rapid weight loss. This has been reported in patients with scoliosis, burns, immobilization in body casts, and idiopathic weight loss. SMA syndrome following bariatric surgery has not been reported. We present 3 cases of SMA syndrome after LRYGBP and extensive weight loss. Two patients underwent laparoscopic duodenojejunostomy and the third patient was treated with intravenous hyperalimentation. All three are symptom free at 4-18 months follow-up. The diagnosis of SMA syndrome should be considered in bariatric surgery patients with rapid weight loss who develop atypical, recurrent obstructive symptoms not attributable to other common causes.     

Epithelial Cell Turnover Is Increased in the Excluded Stomach Mucosa After Roux-en-Y Gastric Bypass for Morbid Obesity

Background

Mucosal alterations after Roux-en-Y gastric bypass for morbid obesity have not been clearly evaluated. This study aims to analyze the mucosal alterations (proliferative status (Ki-67); apoptosis (caspase-3 and BCL-2); hormonal function (gastrin)) in the excluded stomach.

Methods

Double-balloon enteroscopy was performed in 35 patients who underwent Roux-en-Y gastric bypass longer than 36 months. Multiple biopsies of the proximal pouch and the excluded gastric mucosa were collected. Gastric biopsies from 32 non-operated obese patients were utilized as controls. Endoscopic biopsies were cut from tissue blocks fixed in formalin and embedded in paraffin. Sections 4 μm thick were examined for immunoexpression using the streptavidin–biotin–peroxidase method.

Results

The two groups were comparable for age, gender, gastritis, intestinal metaplasia, and Helicobacter pylori. The mean number of positive gastrin cells was 55.5 (standard deviation (SD)?=?11.7) in the control group and 29.6 (SD?=?7.9) in the cases, p?=?0.0003. Ki-67 proliferative index in cases (body?=?24.7 %, antrum?=?24.9 %) was significantly higher compared to controls (body?=?15.0 % and antrum?=?17.7 %), p?=?0.002 and 0.01, respectively. Caspase-3 immunoexpression was higher in the controls compared to the excluded stomach (46 vs. 31 %), p?=?0.02. There was no statistical difference between CD3, CD8, and Bcl-2 immunoexpressions in the control and cases.

Conclusions

Cell proliferation is increased and apoptosis is downregulated in the excluded gastric mucosa compared to the non-operated obese controls. Alterations in cell turnover and in hormonal secretions in these conditions may be of relevance in long-term follow-up.     

Laparoscopic Sleeve Gastrectomy Versus Banded Roux-en-Y Gastric Bypass for Diabetes and Obesity: a Prospective Randomised Double-Blind Trial

Background

There are very few randomised, blinded trials comparing laparoscopic sleeve gastrectomy (LSG) versus laparoscopic Roux-en-Y gastric bypass (LRYGB) in achieving remission of type 2 diabetes (T2D), particularly silastic ring (SR)-LRYGB. We compared the effectiveness of (LSG) versus SR-LRYGB among patients with T2D and morbid obesity.

Methods

Prospective, randomised, parallel, 2-arm, blinded clinical trial conducted in a single Auckland (New Zealand) centre. Eligible patients aged 20–55 years, T2D of at least 6 months duration and BMI 35–65 kg/m² were randomised 1:1 to LSG (n = 58) or SR-LRYGB (n = 56) using random number codes disclosed after anaesthesia induction. Primary outcome was T2D remission defined by different HbA1c thresholds at 1 year. Secondary outcomes included weight loss, quality of life, anxiety and depressive symptoms, post-operative complications and mortality.

Results

Mean ± standard deviation (SD) pre-operative BMI was 42.5 ± 6.2 kg/m², HbA1c 63 ± 16 mmol/mol (30% insulin-treated, 28% had diabetes duration over 10 years). Proportions achieving HbA1c ≤ 38 mmol/mol, < 42 mmol/mol, < 48 mmol/mol and < 53 mmol/mol without diabetes medication at 1 year in SR-LRYGB vs LSG were 38 vs 43% (p = 0.56), 52 vs 49% (p = 0.85), 75 vs 72% (p = 0.83) and 80 vs 77% (p = 0.82), respectively. Mean ± SD % total weight loss at 1 year was greater after SR-LRYGB than LSG: 32.2 ± 7.7 vs 27.1 ± 7.5%, respectively (p < 0.001). Gastrointestinal complications were more frequent after SR-LRYGB (including 3 ulcers, 1 anastomotic leak, 1 abdominal bleeding). Quality of life and depression symptoms improved significantly in both groups.

Conclusion

Despite significantly greater weight loss after SR-LRYGB, there was similar T2D remission and psychosocial improvement after LSG and SR-LRYGB at 1 year.

Trial Registration

Prospectively registered at Australia and New Zealand Clinical Trials Register (ACTRN 12611000751976) and retrospectively registered at Clinical Trials (NCT1486680).