Single-Laparoscopic Incision Transabdominal Surgery Sleeve Gastrectomy

Laparoscopic sleeve gastrectomy has recently been added to the list of appropriate weight loss operations presently performed by bariatric surgeons. The sleeve gastrectomy is routinely performed using five and up to seven laparoscopic trocars with enlargement of one of the trocar sites for extraction of the gastric specimen. We describe a case of laparoscopic sleeve gastrectomy performed through a single laparoscopic incision.     

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.     

Efficacy of Laparoscopic Sleeve Gastrectomy (LSG) as a Stand-Alone Technique for Children with Morbid Obesity

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is basically unknown as a stand-alone technique for bariatric surgery in children and adolescents. It may be advantageous for this age group though, since it requires neither foreign body placement nor life-long malabsorption. We present the first report about the efficacy of LSG in a small pediatric series. METHODS: All patients (n = 4, female) had been in a multi-modal weight loss program for several years without long-term success. At referral, the mean age was 14.5 years (range 8-17), mean body mass index (BMI in kg/m(2)) was 48.4 (range 40.6-56.3). All suffered from various features of a metabolic-vascular syndrome like diabetes, dislipidemia, cholecystolithiasis, arterial hypertension. The 8-year-old girl was diagnosed Prader-Willi Syndrome at the age of 2. The decision for bariatric surgery was taken unanimously by the parents, patient, and the obesity team. LSG was performed in a five-trocar technique. With a gastroscope (size 40-F) protecting the lesser curvature, the stomach was resected from the proximal antrum to the angle of His using an ENDO-GIA stapler. The stapler line was secured by a continuous suture 3-0 vicryl. RESULTS: There were no intra- or postoperative complications. Contrast studies confirmed a J-like gastric remnant (mean volume 76 ml) and ruled out leaks in all cases. After a mean follow-up time of 12 months (range 6-19 months), all the patients had reduced weight (mean BMI to 37.2). The girl with the longest postoperative period went from 121 to 83 kg (BMI from 40.6 to 28.4). Laboratory studies ruled out malnutrition or vitamin deficiency. Monitoring of metabolic parameters showed gradual improvement or even resolution for most features. CONCLUSION: At a 1-year follow-up, LSG proved a safe and effective option for bariatric surgery in children, achieving moderate weight loss and improvement of comorbidities. Thus, it may be considered as stand-alone technique. Long-term studies however must compare these results with time-tested procedures like gastric banding and Roux-en-Y gastric bypass.     

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.     

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 single-port sleeve gastrectomy for morbid obesity: preliminary series

BackgroundLaparoscopic sleeve gastrectomy has been recently proposed as a sole bariatric procedure because of the resulting considerable weight loss in morbidly obese patients. Traditionally, laparoscopic sleeve gastrectomy requires 5–6 skin incisions to allow for placement of multiple trocars. With the introduction of single-incision laparoscopic surgery, multiple abdominal procedures have been performed using a sole umbilical incision, with good cosmetic outcomes. The purpose of our study was to evaluate the feasibility and safety of laparoscopic single incision sleeve gastrectomy for morbid obesity.MethodsA total of 8 consecutive patients underwent laparoscopic single-incision sleeve gastrectomy at the Operative Unit of Bariatric Surgery of the University of Rome Tor Vergata from March 2009 to June 2009.ResultsOf the 8 patients, 5 were women and 3 were men, with a mean age of 44.4 years. The mean preoperative body mass index was 56.2 kg/m². The mean operative time was 128 minutes. The mean postoperative stay was 2.4 days. The mean postoperative body mass index was 49.3 kg/m² at a mean follow-up period of 3.6 months. The mean percentage of excess weight loss was 33% for the same period.ConclusionsLaparoscopic single-incision sleeve gastrectomy seems to be safe, technically feasible, and reproducible. A randomized trial comparing single-incision sleeve gastrectomy and conventional sleeve gastrectomy might be needed to evaluate the postoperative results in relation to the development of abdominal wall complications.     

Single-Incision Sleeve Gastrectomy Using a Novel Technique for Liver Retraction

Introduction:Laparoscopic sleeve gastrectomy has rapidly gained popularity in the field of bariatric surgery, mainly due to its low morbidity and mortality. Traditionally, 4 to 6 trocars are used. Single-access surgery has emerged as an attempt to decrease incisional morbidity and enhance cosmetic benefits. We present our initial 7 patients undergoing single-incision laparoscopic sleeve gastrectomy using a novel technique for liver retraction.Methods:Patients who underwent single-incision laparoscopic sleeve gastrectomy between March 2009 and May 2009 were analyzed. A 4-cm left paramedian incision was used. Laparoscopic sleeve gastrectomy was performed in a standard fashion using a 40 French bougie.Results:Seven patients underwent single-incision sleeve gastrectomy at the University of Illinois at Chicago. They were all female with a mean age of 34 years. Preoperative BMI was 49kg/m² (range, 39 to 64). There were no intraoperative complications. Mean operative time was 103 minutes. Estimated blood loss was minimal. All 7 patients were discharged on postoperative day 2 and were doing well without any complications at 3.1±0.7 months after surgery.Conclusion:Single-incision laparoscopic sleeve gastrectomy is safe and feasible and can be performed without changing the existing principles of the procedure. Our technique for internal liver retraction provides adequate exposure and is reproducible. Development of improved standard instrumentation is required for this technique to become popular.     

Morbid Obesity and Subsequent Pancreatic Cancer: Pylorus-Preserving Pancreatoduodenectomy after Laparoscopic Sleeve Gastrectomy

Morbid obesity is a recognized risk factor for gastrointestinal cancer. Little is known about pancreatic cancer developing after gastric bypass surgery or about surgery for this type of tumor following bariatric surgery. This report describes a case of pancreatic head cancer identified 3 months after laparoscopic sleeve gastrectomy for morbid obesity. During routine follow-up, mild abdominal pain and elevated pancreatic enzymes prompted computed tomography, which revealed mild edematous pancreatitis. Hyperbilirubinemia developed, and magnetic resonance imaging showed a pancreatic head tumor. CA19-9 was elevated. After a pylorus-preserving pancreatic head resection, the postoperative course was uneventful. The patient received adjuvant chemotherapy. Unfortunately, at the time of writing (9 months postoperatively), a local recurrence and hepatic metastases were diagnosed. Patients treated with bariatric surgery who develop new symptoms or report constant mild symptoms should be evaluated using endoscopy and radiomorphological imaging. Interdisciplinary obesity treatment can then offer significant benefits for the patient, particularly in the case of pancreatic cancer, which is still difficult to diagnose. In addition, there is a need for epidemiological studies of patients who undergo bariatric surgery and subsequently develop cancer.     

Deciphering the Sleeve: Technique,Indications, Efficacy,and Safety of Sleeve Gastrectomy

Some institutions perform sleeve gastrectomy (SG) as the initial operation for high-risk, high body mass index patients planning a definitive weight loss operation in 12–18 months. Other institutions consider SG a viable alternative to other bariatric operations. SG is frequently debated among the bariatric surgeons. Many questions remain about the current state of SG. Should it be performed as a definitive weight loss procedure or as a bridge for another bariatric procedure? Is there a specific BMI at which point SG should be encouraged? Is the weight loss comparable to other bariatric procedures? Is there a higher risk of gastric leak? What is the appropriate sleeve size? What are the hormonal benefits? Does SG predispose to gastroesophageal reflux disease? What is the mechanism of weight loss? Are long-term results available? And what are the complications? We conducted an extensive literature review aiming to resolve these commonly asked questions.     

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.     

腹腔镜袖状胃切除术

患者女性，30岁，BMI36.6，诊断代谢综合征。患者平卧"大"字位，头高左侧高30°，主刀右侧站位。距幽门2 cm开始紧贴胃壁游离胃大弯，充分游离胃底，显露左侧膈肌脚及食道左侧，经口置入36 F减重胃管，沿胃管距幽门4 cm开始进行袖状胃裁剪，根据胃壁厚度应用不同钉脚高度的切割闭合钉，连续全层缝合加固胃切缘，并将胃切缘复位固定于大网膜及胰腺背膜，经主操作孔取出切除的胃组织，清理腹腔，放置引流管，缝合戳卡孔。     

Laparoscopic Sleeve Gastrectomy as an Isolated Bariatric Procedure: Intermediate-Term Results from a Large Series in Three Austrian Centers

BACKGROUND: Gastric sleeve resection was initially planned as the first step of bilio-pancreatic diversion with duodenal switch but it continues to emerge as a restrictive bariatric procedure on its own. We describe intermediate results in a series of 126 laparoscopic sleeve gastrectomies (LSG) compiled from three bariatric centers in eastern Austria. METHODS: The stomach was laparoscopically reduced to a "sleeve" along the lesser curvature over a 48-Fr bougie. Special attention was placed on complete resection of the gastric fundus. RESULTS: After a mean follow-up of 19.1 months, patients had lost between 2.3 and 27 kg/m(2) or between 6.7% and 130% of their excessive weight. Sixty four percent of the patients lost >50% of their excess weight within an average of 20 months. Seven percent of the patients had an excess weight loss <25% and were therefore considered as failures. The only major surgical complication was leakage of the staple-line needing revision (three times). There were no operative mortalities. CONCLUSION: The final place of LSG in bariatric surgery is still unclear, but our results and those of others show that LSG can be a viable alternative to established procedures.     

Sleeve Gastrectomy Relieves Steatohepatitis in High-Fat-Diet-Induced Obese Rats

Background  Sleeve gastrectomy is thought to decrease the appetite and body weight of morbid obesity patients in the clinic. The purpose is to investigate the effect of sleeve gastrectomy on preventing steatohepatitis in morbid obesity rats. Methods  Thirty rats were randomized into normal chow group (NC), high-fat-diet group (HD), and sleeve group (SG). Rats in the SG group received sleeve gastrectomy operation. After operation, rats in SG and HD group received a high-fat diet, while rats in the NC group received normal chow. Body weight was measured every 10 days. Thirty days later, animals were sacrificed and blood samples were collected to check total cholesterol, HDL, and triglyceride. Fresh liver sections were made and stained with Nile red and observed under a fluorescence microscope. Results  Rats in the SG group received a moderate body weight decrease (191 ± 16.2 g) in the first 10 days, while this did not happen in the other two groups (213 ± 13.7 g and 243 ± 11.9 g). At the sacrifice date, weight of rats in the SG group was still much lower than those in the HD group. Plasma triglycerol (102.3 ± 18.6 mg/dL) and cholesterol (84.3 ± 6.1 mg/dL) of rats in the SG group were much lower than those in the HD group (198.5 ± 18.5 mg/dL, 133.9 ± 22.0 mg/dL). Under the fluorescence microscope, adipose infiltration was very obvious in the liver of the HD animals, while adipose infiltration was not serious in the SG group. Conclusion  High-fat diet can result in obvious body weight increase and hepatic adipose infiltration compared with normal chow. Sleeve gastrectomy can decrease body weight even in high-fat-diet models. Body weight control caused by sleeve gastrectomy can relieve high-fat-diet-induced steatohepatitis in rats. Authors have no commercial interest in the subject of study. This investigation was supported by National Foundation of Liaoning Province (110035).     

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。     

Influence of Sleeve Gastrectomy on Several Experimental Models of Obesity: Metabolic and Hormonal Implications

Background Ghrelin is an important factor in the regulation of intake. Most ghrelin is synthesized in the gastric fundus, but this is not the only location. The aim of this experimental study was to analyze the effect of sleeve gastrectomy (removing fundus) on the volume of intake in four experimental models and determine how this relates to changes in weight, plasmatic levels of glycemia, ghrelin, GLP-1, and insulin. Methods Sleeve gastrectomy was performed on four experimental models: (1) non-obesity; (2) exogenous obesity caused by excessive calorie intake; (3) genetically determined obesity (Zucker rats); and (4) genetically determined obesity and type 2 diabetes mellitus (Zucker diabetic fatty; ZDF rats). Model 2 had a control group on which sleeve gastrectomy was not performed. Results In the non-obese group, there were few changes after intervention, but in model 2, sleeve gastrectomy led to normalization of weight and endocrine–metabolic parameters that were the same as those for non-obese rats. The exception was for GLP-1, which has an anorexigenic effect: GLP-1 remained higher. In Zucker rats, sleeve gastrectomy had a slight effect on all parameters. In ZDF rats, sleeve gastrectomy led to a reduction in intake and a stabilization of weight. Conclusions Sleeve gastrectomy is a very good option for exogenous obesity. Normalization of hormonal levels led us to find an extragastric ghrelin production.     

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.     

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.     

Indications for Sleeve Gastrectomy as a Primary Procedure for Weight Loss in the Morbidly Obese

Background Single-stage laparoscopic sleeve gastrectomy (LSG) may represent an additional surgical option for morbid obesity. Methods We performed a retrospective review of a prospectively maintained database of LSG performed from November 2004 to April 2007 as a one-stage primary restrictive procedure. Results One hundred forty-eight LSGs were performed as primary procedures for weight loss. The mean patient age was 42 years (range, 13–79), mean body mass index of 43.4 kg/m² (range, 35–75), mean operative time of 60 min (range, 58–190), and mean blood loss of 60 ml (range, 0–300). One hundred forty-seven procedures (99.3%) were completed laparoscopically, with a mean hospital stay of 2.7 days (range, 2–25). A 2.7% major complication rate was observed with four events in three patients and no deaths. Four patients required readmission; mild dehydration in two, choledocholithiasis in one, and a gastric sleeve stricture in one. Conclusion Laparoscopic SG is a safe one-stage restrictive technique as a primary procedure for weight loss in the morbidly obese with an acceptable operative time, intraoperative blood loss, and perioperative complication rate. This work was presented at the SSAT Poster Presentation session on May 21st 2007 at the SSAT Annual Meeting at Digestive Disease Week, Washington. Poster ID M1588.     

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.