Sleeve Gastrectomy after Renal Transplantation

Background

Obesity induces or accelerates diabetes (DBT), hypertension (HT), and dyslipidemia (DSL), which are the main causes of renal failure. Obesity exacerbates in patients after renal transplantation (RT), and it has been associated with increased mortality rate, postoperative complications, and graft loss. We hypothesize that bariatric surgery might have a positive effect on obese patients with history of previous RT.

Methods

This was a retrospective review from prospectively collected data. Patients with sleeve gastrectomy (SG) with history of RT were studied. Demographics, anthropometric data, effect on comorbidities, postoperative course, immunosuppressive treatment, reason for transplantation, kidney function, graft survival, and quality of life associated with SG in obese patients with previous RT were assessed using a survey.

Results

From January 1, 2012 to January 1, 2016, five kidney transplant patients were operated on; 80% were female, with an average preoperative BMI of 42.18?±?8.5 kg/m² (range 37–54). Related comorbidities: 100% of the patients had HT and DSL, whereas 40% had DBT and gout. The average time gap between RT and SG was 15?±?8.4 years (range 3–22). Average operative time was 65?±?12 min (range 60–85), and there were neither complications nor mortality. At 16.8?±?14.5 months (range 5–46) of follow-up, BMI was 29.8?±?7.3 kg/m² (range 26–44). All patients with HT and DSL were able to decrease their medication, showing improvement in blood pressure levels and laboratory test values. Regarding DBT, insulin was discontinued in one case, limiting the treatment to the use of oral hypoglycemic agents only. In another case, insulin dosage was significantly reduced. Graft function and proteinuria level improved in 80% of patients. All patients experienced a significant improvement in their quality of life.

Conclusion

In this specific group of high-risk patients, SG showed encouraging results in terms of weight loss and resolution/improvement of comorbidities, renal function, and quality of life.

     

Prevalence and Predictors of Gastroesophageal Reflux Disease After Laparoscopic Sleeve Gastrectomy

Background and Aims

Laparoscopic sleeve gastrectomy (LSG) might be associated with a new onset or worsening of gastroesophageal reflux disease (GERD). We aim to evaluate the prevalence of post-LSG GERD symptoms and its predictors.

Methods

We included patients who underwent primary LSG at a university hospital from 2009 to 2015. We used the GERD-Health-Related Quality of Life (GERD-HRQL) questionnaire and included questions regarding regurgitation to evaluate symptoms before and after LSG; each item was scored from 1 to 5 based on the symptom severity.

Results

A total of 213 patients (mean age, 36.08 ± 10.22 years; 48.36% were men) were included. The mean preoperative body mass index (BMI) was 47.84 kg/m², mean percent total weight loss was 37.99% (95% CI, 36.64 to 39.34), mean percent excess weight loss was 84.14% (95% CI, 80.91 to 87.36), and the mean percent excess BMI loss was 84.17% (95% CI, 80.94 to 87.41). The mean heartburn score while standing increased (0.71 vs. 1.09, p < 0.01) as well as the score of heartburn requiring a diet change (0.67 vs. 1.16, p < 0.01) post-LSG. The scores for dysphagia, odynophagia, and regurgitation increased. New-onset heartburn was reported in 47.06% of our cohort. Those with high preoperative BMIs were less likely to develop new-onset or worsening symptoms of GERD (odds ratio [OR], 0.97; 95% confidence interval [CI], 0.95–0.99). More severe heartburn symptoms while standing were associated with higher risks of developing or worsening GERD symptoms (OR, 1.22; 95% CI, 1.01–1.47). None of the other variables could predict the development or worsening of the GERD symptoms.

Conclusion

Symptoms of heartburn and regurgitation are common after LSG; however, none of the variables preoperatively could strongly predict patients who would develop new onset or experience worsening of symptoms postoperatively.

     

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.     

Impact of Laparoscopic Sleeve Gastrectomy on Iron Indices: 1 Year Follow-Up

Background  

Laparoscopic sleeve gastrectomy (LSG) has been recently introduced as a stand-alone, restrictive bariatric surgery. Theoretically, LSG attenuates micronutrients deficiencies and associated complications that typically observed following malabsorptive procedures. The aim of this study was to assess iron indices and the 1-year incidence of iron deficiency in patients undergoing LSG.     

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.     

Sleeve Gastrectomy as Treatment for Severe Obesity after Orthotopic Liver Transplantation

Obesity is highly prevalent in both liver transplant candidates and recipients, and can have a significant impact on perioperative morbidity and mortality and the overall cost of transplantation. Herein, we describe an obese patient who was managed sequentially with an intragastric balloon in the pre-transplant setting and a gastric sleeve following transplantation, with good long-term results. Sleeve gastrectomy is a non-malabsorptive bariatric procedure with potential benefit for liver transplant patients due to its lack of influence on the absorption of immunosuppressive agents.     

Predictors of Weight Loss are Different in Men and Women After Sleeve Gastrectomy

Background

Weight loss following bariatric surgery varies according to patient factors before the intervention. However, whether predictors of weight loss differ between men and women is, to our knowledge, unknown. We therefore aimed to investigate baseline predictors for overall weight loss and identify potential sex-specific baseline predictors in bariatric surgery patients.

Methods

In this prospective cohort study, 160 patients (117 women and 43 men) who underwent sleeve gastrectomy were followed up for 2 years. Weight loss was defined as percent excess body mass index loss (%EBMIL). To investigate whether %EBMIL differed between men and women, we included all two-way interactions with sex by incorporating the product term sex and predictors using multiple linear regression analysis.

Results

The overall mean ± standard deviation of %EBMIL after 2 years was 78.3?±?23.5. Predictors for lower %EBMIL in a regression model with no interactions were female sex (P?=?0.003), higher body mass index before surgery (P?=?0.001), and nonsmoking (P?=?0.029). When examining sex-specific predictors for %EBMIL, higher age (P?=?0.027) and not having diabetes (P?=?0.007) predicted lower %EBMIL in men. In women, unemployment (P?=?0.006) and anxiety and/or depression (P?=?0.009) predicted lower %EBMIL.

Conclusions

This study suggests that weight loss and predictors for weight loss 2 years after sleeve gastrectomy are sex-specific. These findings may be useful for the surgical strategy used to treat these patients.     

Sleeve Gastrectomy Leads to Helicobacter pylori Eradication

Background  The role of Helicobacter pylori (HP) in patients scheduled and undergoing laparoscopic sleeve gastrectomy (LSG) has not been previously evaluated. Methods  Included were obese patients presenting to our institution for LSG over 24 months. All patients had presurgical HP breath test, and the symptomatic ones received triple therapy with symptom follow-up. Post surgery, all excluded stomachs were evaluated for HP, and those that were positive performed a second ¹³C-urea breath test (UBT) 3 months later. Results  Forty patients underwent LSG. Male to female sex ratio was 1:3; mean age—42 years; mean weight—122 kg; and mean BMI of 43.4 kg/m². Presurgical HP was positive in 15 (37.5%) patients (11 symptomatic and four asymptomatic). Only these 11 patients were given HP eradication therapy and all experienced complete subsequent symptom resolution. HP was detected in 17 out of the 40 (42.5%) cases of excluded stomachs. All performed a ¹³C-UBT 3 months post operation and only three (17.6%) tested positive. Conclusions  HP infection is frequent in biopsies from patients with previous LSG and the majority of follow-up ¹³C-UBT were negative. In our small initial sample, we treated only symptomatic patients preoperatively. Routine screening for HP for all LSG patients and/or treatment for all positive ones would subject patients to expensive and unnecessary investigations. We propose that this stomach-reducing, pylorus-preserving surgery might even lead to HP eradication. The clinical implications of HP and this gastrectomy for a non-neoplastic, non-peptic indication deserve further study.     

Laparoscopic Sleeve Gastrectomy in Patients over 59 Years: Early Recovery and 12-Month Follow-Up

Background  

Bariatric surgery has shown to be safe for patients over 60 years with good results especially considering resolving of comorbidities. Sleeve gastrectomy is considered to be safer than gastric bypass (GBP) and more effective than gastric banding with less adverse symptoms. Weight loss may be more modest than after GBP, but the effect on vitamins may also be milder.     

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.     

Laparoscopic Sleeve Gastrectomy for Late Adolescent Population

Background

Morbid obesity prevalence is rapidly increasing among adolescents worldwide. Evidence is mounting that bariatric surgery is the only reliable method for substantial and sustainable weight loss; however, the debate continues with regard to the optimal surgical procedure for adolescents and to the age limit when bariatric surgery should be proposed.

Methods

A retrospective multicenter review included all late adolescent patients (<20 years old) who underwent sleeve gastrectomy from 2005 to 2012 in three French bariatric centers: Montpellier University Hospital, Casamance Private Hospital, and Noumea Regional Hospital. Collected data included age, sex, body mass index (BMI), intraoperative complications, length of hospital stay, operative morbidity, the need for reoperation, and percentage of excess weight loss (% EWL) at 6 months, 1 year, and 2 years postoperatively.

Results

A total of 61 adolescent patients have undergone sleeve gastrectomy. Of these, 42 were women and 19 were men. The mean preoperative weight was 132.8 kg (range 90–217 kg) with a BMI of 46.7 (range 35.5–68.7). Seventeen patients (27.9 %) were superobese (BMI?>?50), and seven patients (11.5 %) were supersuperobese (BMI?>?60). All the procedures were performed by laparoscopy with no intraoperative complications. The mean hospital stay was 4.6 days. Four major complications were recorded: one staple line leak, two hematomas, and one case of pneumonia. No mortality was recorded. The % EWL at 6 months, 1 year, and 2 years postoperatively was 48.1 % (±17.9 %), 66.7 % (±19.5 %), and 78.4 % (±16.8 %), respectively, for a follow-up of 93.4, 81.9, and 52.4 %, respectively. There were 18 patients (29.5 %) with identified comorbid conditions: 10 cases of sleep apnea, 7 cases of hypertension, and 1 case of type 2 diabetes, with a resolution rate of 77.8 %.

Conclusions

Laparoscopic sleeve gastrectomy may be advantageous for this age group, since it involves neither foreign body placement nor lifelong malabsorption. Laparoscopic sleeve gastrectomy represents an attractive bariatric procedure for adolescent patients, more efficient than gastric banding and with less morbidity compared to gastric bypass.     

Previous Bariatric Surgery Increases Postoperative Morbidity after Sleeve Gastrectomy for Morbid Obesity

Objectives : Sleeve gastrectomy (SG) has been used as the first step of a staged malabsorptive procedure for high-risk patients. More recently SG was proposed as an stand alone procedure in the treatment of morbidly obese patients. The aim of this study is to analyze perioperative outcome of morbid obese patients after SG. Methods : 301 patients, 201 women and 100 men, undergoing SG were retrospectively analyzed. SG was performed by 17 surgeons all member of the Club Coelio.

The mean BMI was 44.7kg/m² (27.4–70.3 kg/m²). 34 patients (11.3%) of our series had SG as revisional surgery. These revisional procedures consisted of 32 conversions from gastric banding, 1 conversion from vertical gastroplasty (VBG) and 1 from transoral endoscopic gastroplasty. Among the 32 patients that had revisional SG after a gastric banding, 13 bands were removed at least 3 months before the revisional SG and 19 bands were removed during the SG procedure. Endpoints were perioperative morbidity and mortality and potential risk factors for complications, mainly per or postoperative bleeding or leakage.

Results : Overall mortality was 0% and morbidity was 10.3%. Perioperative bleeding occurred in 10 patients (3.3%), leakage in 12 patients (4%) patients and stenosis in 3 patients (1%). The risk of leakage was significantly higher after revisional bariatric surgery and in case of gastric perforation during surgery(p = 0.0001). Previous gastric banding is also associated with a higher risk of postoperative bleeding (p = 0.0006).

Conclusions : SG can be safely performed but patients and surgeons must be aware of a higher risk of postoperative complications when SG is proposed as a revisional surgery.     

Re-sleeve Gastrectomy for Failed Laparoscopic Sleeve Gastrectomy: A Feasibility Study

Background  

Laparoscopic sleeve gastrectomy (LSG) has been rapidly accepted as a valuable bariatric procedure before its effectiveness on weight loss in the long-term is clearly demonstrated. We report a feasibility study including 13 patients undergoing a redo LSG for either progressive weight regain after initial weight loss of insufficient weight loss.     

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.     

Primary Sleeve Gastrectomy Compared to Sleeve Gastrectomy as Revisional Surgery: Weight Loss and Complications at Intermediate Follow-up

Introduction

The laparoscopic adjustable gastric band (LAGB) can be revised to sleeve gastrectomy (LSG) for various reasons. Data are limited on the safety and efficacy of single-stage removal of LAGB and creation of LSG.

Methods

A retrospective review of cases was performed from 2010 to 2013. From the primary LSG group, a control group was matched in a 2:1 ratio.

Results

Thirty-two patients underwent single-stage revision from LAGB to LSG, with a control group of 64. The most common indication for revision was insufficient weight loss (62.5 %). Operative time for revision and control groups was 134 and 92 min, respectively (p?p?=?0.02). Overall, the 30-day complication rate for revision and control patients was 14.71 and 6.25 %, respectively (p?=?0.20). There were no leaks, one stricture (3.13 %) in the revision group, and one reoperation for bleeding in the control group (1.56 %). For patients with BMI >30 at surgery, change in BMI at 12 months for revision and control was 8.77 and 11.58, respectively (p?=?0.02).

Conclusion

Single-stage revision can be performed safely, with minimal increases in hospital stay and 30-day complications. Weight loss is greater in those who undergo primary LSG compared to those who undergo LSG as revision.     

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.     

Excessive Weight Loss after Sleeve Gastrectomy: A Systematic Review

Background  

The clinical significance of sleeve gastrectomy (SG) as a primary bariatric intervention is still under debate. This article aims to systematically analyze excessive weight loss (EWL) in patients after SG.