Effectiveness of Laparoscopic Sleeve Gastrectomy (First Stage of Biliopancreatic Diversion with Duodenal Switch) on Co-Morbidities in Super-Obese High-Risk Patients

Authors: Silecchia, Gianfranco¹; Boru, Cristian¹; Pecchia, Alessandro¹; Rizzello, Mario¹; Casella, Giovanni¹; Leonetti, Frida²; Basso, Nicola¹

Source: Obesity Surgery, Volume 16, Number 9, September 2006 , pp. 1138-1144(7)

Publisher: Springer

Abstract:

Background: We evaluated laparoscopic sleeve gastrectomy (LSG) on major co-morbidities (hypertension, type 2 diabetes / impaired glucose tolerance, obstructive sleep apnea syndrome (OSAS) and on American Society of Anesthesiologists (ASA) operative risk score in high-risk super-obese patients undergoing two-stage laparoscopic biliopancreatic diversion with duodenal switch (LBPD-DS).

Methods: 41 super-obese high-risk patients (mean BMI 57.3±6.5 kg/m2, age 44.6±9.7 years) were entered into a prospective study (BMI ≥60, or BMI ≥50 with at least two severe co-morbidities, no Prader-Willi syndrome, no conversion, minimum follow-up 12 months). 9 patients had BMI ≥60. 17 patients (41.4%) had OSAS on C-PAP therapy. In 10 patients, at least one intragastric balloon had been positioned and 4 had undergone laparoscopic adjustable gastric banding, all with unsatisfactory results. At surgery, 41.5% were classified ASA 4 and 58.5% as ASA 3 (mean ASA score 3.4±0.5). Patients underwent evaluation every 3 months postoperatively and were restaged at 12 months and/or before the second step.

Results: 60% of major co-morbidities were cured and 24% improved. Average BMI after 6 and 12 months was 44.5±8.1 and 40.8±8.5 respectively (mean follow-up 22.2±7.1 months). After 12 months, 57.8% of the patients were co-morbidity-free and 31.5% had only one major co-morbid condition. At restaging, 20% of patients were still classified as ASA score 4 (OSAS on C-PAP therapy). 3 patients showed BMI <30 and were co-morbidity-free 12 months after LSG.

Conclusions: LSG represents a safe and effective procedure to achieve marked weight loss as well as significant reduction of major obesity-related co-morbidities. The procedure reduced the operative risk (ASA score) in super-obese patients undergoing two-stage LBPD-DS.

Laparoscopic Sleeve Gastrectomy as Treatment for Morbid Obesity: Technique and Short-Term Outcome

Authors: Roa, Paul E.¹; Kaidar-Person, Orit¹; Pinto, David¹; Cho, Minyoung²; Szomstein, Samuel¹; Rosenthal, Raul J.¹

Source: Obesity Surgery, Volume 16, Number 10, October 2006 , pp. 1323-1326(4)

Publisher: Springer

Abstract:

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) and laparoscopic adjustable gastric banding (LAGB) are the most commonly performed surgical procedures for weight reduction in the . Currently, laparoscopic sleeve gastrectomy (LSG) is being explored. The aim of this study was to assess the safety and short-term efficacy of LSG as a treatment option for weight reduction.

Methods: Data of all patients who underwent LSG for treatment of morbid obesity between November 2004 and March 2006 and completed the 3- and 6-month follow-up visits at the time of the study, were retrospectively reviewed. Data collected included demographics, operative time, length of stay, postoperative complications, and degree of weight reduction.

Results: Of the 62 patients who underwent LSG performed by two surgeons, the data of 30 patients (7 males and 23 females) were further analyzed. Mean preoperative BMI was 41.4 (33-59) kg/m2. Mean operative time was 80 min (range 65-130). Mean hospital stay was 3.2 days (range 2 to 25). Mean weight loss at 3 and 6 months following the procedure was 22.7 kg and 30.5 kg respectively, and mean % excess weight loss (EWL) was 40.7 and 52.8, respectively. Three patients were considered to have mild complications, and one patient had a major complication that necessitated surgical intervention. There was no mortality.

Conclusions: In the short-term, LSG is a safe and effective treatment option.

Re-Sleeve Gastrectomy

Authors: Baltasar, Aniceto¹; Serra, Carlos¹; Pérez, Nieves¹; Bou, Rafael¹; Bengochea, Marcelo¹

Source: Obesity Surgery, Volume 16, Number 11, November 2006 , pp. 1535-1538(4)

Publisher: Springer

Abstract:

Background: Laparoscopic sleeve gastrectomy (LSG) started as the restrictive part of the more complex laparoscopic duodenal switch (LDS) operation. There is no long-term experience with the isolated LSG. The main concern about the isolated LSG is the possibility of dilatation of the gastric pouch, long-term loss of restrictive function and weight regain. Laparoscopic re-sleeve gastrectomy (LRSG) has been used sparingly, but it also may become a possibility if more patients have the isolated LSG.

Methods: 2 patients with BMI 58 and 65 respectively, underwent LSG as the first stage of the LDS. Later, when the patients regained some weight and their gastric pouch was found to be too large, the LRSG/DS was done.

Results: The patient with BMI 58 had an initial drop to BMI 34 and regained weight to BMI 46, but after the LRSG/DS her BMI is 36 at 4 months. The BMI patient with BMI 65 had a drop to BMI 42, and after the LRSG/DS his BMI is 33 at 3 months later.

Conclusion: LRSG may become necessary after gastric tube dilatation or insufficient original gastric volume reduction. LRSG is feasible, available and easy to perform when the resulting gastric pouch is too large or dilates after the original LSG.

Sleeve Gastrectomy in the High-Risk Patient

Authors: Hamoui, Nahid¹; Anthone, Gary J.¹; Kaufman, Howard S.¹; Crookes, Peter F.¹

Source: Obesity Surgery, Volume 16, Number 11, November 2006 , pp. 1445-1449(5)

Publisher: Springer

Abstract:

Background: One of the surgical options available for the super-obese patient is the sleeve gastrectomy. We present results of this operation in a series of 118 patients.

Methods: The charts of all patients who have had the sleeve gastrectomy performed were reviewed for demographic data, complications, weight, and nutritional parameters.

Results: Median age was 47 years (16-70). Median BMI was 55 kg/m2 (37-108), with 73% of patients having a BMI ≥50 kg/m2. 41% of the patients were male. The operation was performed by laparotomy in all but three cases, which were performed laparoscopically. Median hospital stay was 6 days (3-59). There was one perioperative death (0.85%). 18 patients (15.3%) had postoperative complications. Median percent excess weight loss was 37.8% at 6 months, 49.4% at 12 months, and 47.3% at 24 months. Median follow-up was 13 months (1-66). At 1 year postoperatively, the percentage of patients with normal serum levels of albumin was 100%, hemoglobin 86.1%, and calcium 87.2%, compared to 98.1%, 85.6%, and 94.3% preoperatively. 6 patients requested conversion to a duodenal switch during the follow-up period; all left the hospital in 4-6 days without major complication.

Conclusions: Although the sleeve gastrectomy does not result in as much weight loss as the duodenal switch or gastric bypass, it can be used as a stand-alone operation or as a bridge to more complex procedures in the high-risk super-obese patient.

The Effect of Biliopancreatic Diversion with Pylorus-Preserving Sleeve Gastrectomy and Duodenal Switch on Fasting Serum Ghrelin, Leptin and Adiponectin Levels: Is there a Hormonal Contribution to the Weight-Reducing Effect of this Procedure?

Authors: Kotidis, Efstathios; Koliakos, George; Papavramidis, Theodosios; Papavramidis, Spiros

Source: Obesity Surgery, Volume 16, Number 5, May 2006 , pp. 554-559(6)

Publisher: Springer

Abstract:

Background: Ghrelin is a peptide hormone with orexigenic properties, primarily produced by the stomach. Different changes in fasting ghrelin levels have been reported following bariatric surgery. In this study, we investigate the hypothesis that because ghrelin is mainly produced by the fundus of the stomach, biliopancreatic diversion with sleeve gastrectomy with total resection of the gastric fundus and duodenal switch (BPD-DS) will cause substantial decrease in circulating ghrelin levels.

Methods: Serum fasting ghrelin, leptin and adiponectin concentrations were measured by ELISA in 13 patients with morbid obesity who achieved weight loss by BPD-DS, before the operation and 18 months after.

Results: After BPD-DS, BMI decreased significantly, from 59.15±15.82 kg/m2 to 32.91±6.46 kg/m2 (P=0.001). Serum fasting ghrelin level decreased from 1.44±0.77 ng/ml to 0.99±0.35 ng/ml (P=0.019). Serum leptin level decreased from 1.81±0.38 ng/ml to 1.65±0.32 ng/ml, (P=0.196), and adiponectin level increased from 37.85±11.24 μg/ml to 39.84±16.27 μg/ml (P=0.422).

Conclusions: BPD-DS is associated with markedly suppressed ghrelin levels, possibly contributing to the longlasting weight-reducing effect of the procedure. Leptin levels decreased and adiponectin increased, as expected, after weight loss. Sleeve gastrectomy with resection of the gastric fundus seems to be the main cause of the postoperative reduction in ghrelin levels.

Does Gastric Dilatation Limit the Success of Sleeve Gastrectomy as a Sole Operation for Morbid Obesity?

Authors: Langer, Felix; Bohdjalian, Arthur; Felberbauer, Franz; Fleischmann, Edith; Reza Hoda, Mir; Ludvik, Bernhard; Zacherl, Johannes; Jakesz, Raimund; Prager, Gerhard

Source: Obesity Surgery, Volume 16, Number 2, February 2006 , pp. 166-171(6)

Publisher: Springer

Abstract:

Background: Sleeve gastrectomy as the sole bariatric operation has been reported for high-risk super-obese patients or as first-step followed by Roux-en-Y gastric bypass (RYGBP) or duodenal switch (DS) in super-super obese patients. The efficacy of laparoscopic sleeve gastrectomy (LSG) for morbidly obese patients with a BMI of <50 kg/m2 and the incidence of gastric dilatation following LSG have not yet been investigated.

Methods: 23 patients (15 morbidly obese, 8 super-obese) were studied prospectively for weight loss following LSG. The incidence of sleeve dilatation was assessed by upper GI contrast studies in patients with a follow-up of >12 months.

Results: Patients who underwent LSG achieved a mean excess weight loss (EWL) at 6 and 12 months postoperatively of 46% and 56%, respectively. No significant differences were observed in %EWL comparing obese and super-obese patients. At a mean follow-up of 20 months, dilatation of the gastric sleeve was found in 1 patient and weight regain after initial successful weight loss in 3 of the 23 patients.

Conclusion: LSG has been highly effective for weight reduction for morbid obesity even as the sole bariatric operation. Gastric dilatation was found in only 1 patient in this short-term follow-up. Weight regain following LSG may require conversion to RYGBP or DS. Follow-up will be necessary to evaluate long-term results.

Laparoscopic Sleeve Gastrectomy: A Multi-purpose Bariatric Operation

Authors: Baltasar, Aniceto¹; Serra, Carlos²; Pérez, Nieves²; Bou, Rafael²; Bengochea, Marcelo²; Ferri, Lirios²

Source: Obesity Surgery, Volume 15, Number 8, September 2005 , pp. 1124-1128(5)

Publisher: Springer

Abstract:

Background: The use of the laparoscopic sleeve gastrectomy (LSG), a restrictive operation, in different settings, is presented.

Methods: 31 patients underwent LSG in the following groups: 1) 7 patients with very high BMI as a first stage of the duodenal switch (DS); 2) 7 morbidly obese patients with severe medical conditions; 3) 16 obese patients with lower BMI (35-43); and 4) 1 patient converted from a prior gastric banding.

Results: 1 patient with BMI 74 died, a 3.2% mortality. The percentage of excess BMI loss (%EBMIL) in group 1 above was 63.1% from 4-27 months. The %EBMIL of the cirrhotics in group 2 was 76.0% (69-100%). The %EBMIL in group 3 patients was 68.5% (58.3-123%) at 3-27 months. The %EBMIL of the group 4 patient is 13% because she had previously lost almost all of her EBMI.

Conclusion: LSG may become the ideal operation for staging in patients with BMI >55, for treating morbidly obese patients with severe medical conditions, as an excellent alternative to adjustable bands in lower BMI patients, or for conversion of gastric banding patients.

LAPAROSCOPIC SLEEVE GASTRECTOMY FOR MORBIDLY OBESE PATIENTS

Authors: OuYang, S. O.; Loi, K.; Jorgensen, J.; Talbot, M.

Source: ANZ Journal of Surgery, Volume 77, Supplement 1, May 2007 , pp. A45-A45(1)

Publisher: Blackwell Publishing

Abstract:

Background Obesity surgery is been endorsed as the only effective method of weight reduction in morbidly obese patients. Laparoscopic Roux-en-Y gastric bypass (LRYGBP) is been used as the most effective procedures in our centre. However LRYGBP also conveys high risk of peri- and postoperative complications on obese patients. Laparoscopic sleeve gastrectomy (LSG) is been employed first-stage procedure as a risk reduction strategy. The aim of this study was to report the short-term outcomes of LSG, its effect on risk reduction and resolution in co-morbidities.

Methods We prospectively investigated 92 patients who underwent LSG between July 2004 and February 2006 and completed our data collection through 3- to 6-monthly follow up and/or patient questionnaire. Data collected included demographics, degree of weight reduction, postoperative complications, and changes in  co-morbidities.

Results Median BMI was 52.03 kg/m2 (33-82). 56% patients had a BMI >50 kg/m2. The median postoperative excess weight loss (EWL) was 45% with 35.49% at 6 months, 49.07% at 12 months, and 55.75% at 18 months. 39% of patients had resolutions in Diabetes Mellitus type 2, 56% had resolutions in dyslipidaemia, 28% in hypertension, 66% in obstructive sleep apnoea. Complication rate of 7.5% and three patients necessitated  surgical intervention. There was zero mortality.

Conclusion LSG minimizes postoperative complication rates significantly on high risk patients and achieves effective short-term weight loss with resolutions in co-morbidities. Additional studies are required to evaluate LSG as a stand-lone procedure.

Laparoscopic Sleeve Gastrectomy for Weight Loss in

Morbid Obesity

Olga N. Tucker*, Samuel Szomstein, Raul J. Rosenthal Minimally Invasive Surgery, Cleveland Clinic Florida, Weston, FL (2004-2006)

Single-stage laparoscopic sleeve gastrectomy (LSG) may represent an additional surgical option in the treatment of morbid obesity. We performed a retrospective review of a prospectively maintained database of patients undergoing LSG from Nov 2004 to Oct 2006 as a one-stage restrictive procedure. 119 LSGs were performed. 105 (88%) were primary procedures; M:F = 1:3, mean age 42 yrs (range 13–79), mean BMI 43 kg/m2 (range 35–66). All procedures were completed laparoscopically. The mean duration of surgery was 94 mins (range 60–180) with a mean blood loss of 65 mls (range 20–300). The mean length of hospital stay was 2 days. 1 patient underwent reintervention for abdominal pain on postoperative day (POD) 1 requiring laparoscopic primary closure of a staple line leak close to the gastrooesophageal junction. Short-term outcome data is available on 66 patients (71%) who have been followed for >3 mon; 52 patients (56%) have >6 mon follow-up with >1 yr follow up in 16 patients (17%). The mean weight loss is 24 kg (range 19–30) at 6 mon and 51 kg (range 24–44) at 1 yr. A further 14 patients (12%) had a LSG after failed laparoscopic adjustable gastric banding (n = 11), failed attempt at laparoscopic Roux-en-Y gastric bypass due to adhesions (n = 1), or previous jejunoileal bypass with weight regain (n = 2); M:F = 1:4, mean age 48 yrs (range 16–69), mean BMI 41 kg/m2 (range 35–55). Only 1 procedure was not completed laparoscopically (7%). This patient had a jejunoileal bypass >30 yrs previously and had chronic renal and liver failure. All 11 laparoscopic adjustable bands were removed during the same procedure. Mean operative time was 122 mins (range 85–180), mean blood loss was 98 mls (range 40–200), and mean length of hospital stay was 2.9 days (range 2–4). 1 patient underwent reintervention for abdominal pain on POD 2 requiring primary closure and omental patchplasty of a presumed ischaemic perforation adjacent to the staple line secondary to a coagulation injury. In summary, 2 patients required reintervention in our series resulting in a major complication rate of 1.8%. All patients had a gastrograffin swallow on POD 1 allowing early leak detection. A further 3 patients required readmission for mild dehydration. In conclusion, LSG is an effective and safe primary restrictive procedure to achieve weight loss.

Results of Laparoscopic Sleeve Gastrectomy (LSG) at 1 Year in Morbidly Obese Korean Patients

Authors: Moon Han, Sang¹; Kim, Won Woo¹; Oh, Ji Hyun¹

Source: Obesity Surgery, Volume 15, Number 10, November/December 2005 , pp. 1469-1475(7)

Publisher: Springer

Abstract:

Background: In Asia, the type and main cause of obesity is different than in western society. Therefore, the treatment plan should be differentiated, and the surgery for morbid obesity should be carefully chosen. The early results of laparoscopic sleeve gastrectomy (LSG) without duodenal switch that has been performed in the Korean population is reported.

Methods: We retrospectively reviewed 130 patients who underwent LSG from January 2003 to May 2004. 60 of these patients now had >1 year of regular follow-up, and are the subject of this report. LSG was performed through 4 12-mm ports and 1 15-mm port, using the Endo-GIA stapler to create a lesser curve gastric tube over a 48-Fr bougie.

Results: For the 60 patients, the postoperative EWL was 71.6±21.9% at 6 months and 83.3±28.3% at 12 months. At 12 months after LSG, decrease in BMI was 9.2±3.7 kg/m2, and median weight loss was 24.6±10.0 kg. Dyslipidemia resolved in 75% of patients within 12 months. Diabetes resolved in 100% of patients within 6 months of operation. Hypertension resolved in 92.9% and improved in 100%. Joint pain resolved in 100% within 12 months. Weight loss plateaued at 12 months in the majority of patients. One patient has undergone a malabsorption procedure (duodenal switch) as a second-stage operation.

Conclusion: Additional studies and follow-up are needed to determine the best surgical treatment for morbidly obese Asian patients. However, LSG without the second-stage duodenal switch operation has been an effective weight loss operation thus far, in most of the Korean patients.