Laparoscopic Sleeve Gastrectomy. A
multi-purpose bariatric operation
Aniceto Baltasar MD 1, Carlos Serra MD 2, Nieves Pérez MD
2,
Rafael Bou MD 2, Marcelo Bengochea MD 2, Lirios Ferri 2
(*) Chief of the Surgical Service
(**) Surgical Staff
Clínica San Jorge & Alcoy Hospital.
Alcoy. Spain
A. Baltasar, MD
c/ Cid 61
03803 Alcoy
Alicante. Spain
abaltasar@seco.org
baltasar_ani@gva.es
Short-title: “LapSG”
Phone (+34) 96-553.74.39
FAX (+34) 96-533.04.00
2
Abstract:
Background: We present our experience with the use of the LSG
(laparoscopic sleeve gastrectomy), a restrictive procedure, in different
settings.
Methods: Thirty–one patients had the LSG for: I) Seven patient with very
high BMI as a first stage of the DS (Duodenal Switch); II) Seven morbidly
obese patients with severe medical conditions; III) Sixteen obese patients
with low BMI (35 to 43); and IV) One patient converted from a lap-band.
Results: One patient with BMI-74 died, 3.2% mortality. The %EBMIL
(percentage BMI loss) of I patients is 63.1% from 4 to 27 months. The
%EBMIL of the cirrhotic II patients is 76.0% (69 to 100). The %EBMIL of III
patients is 68.5% (from 58.3 to 123%) at 3 to 27 months. The %EBMIL of the
IV patient is 13% since she has lost previously almost all her EBMI.
Conclusion: LSG may become the ideal operation for staging high > 55%
BMI patients, treat morbidly obese patients with severe medical conditions,
an excellent alternative to adjustable bands in low BMI patients or
conversion of the lap-band patients.
Key words: Sleeve gastrectomy. Laparoscopy. Obesity surgery.
3
Introduction:
SG (sleeve gastrectomy) is the restrictive part of the more extensive mixed
restrictive and mal-absorptive operation, the BPD/DS (Bilio-pancreatic
diversion-Duodenal Switch). Hess
1, 2
performed the first DS (Duodenal
Switch) operation in March 1988 (in a lady with a BMI of 60 and 17 years
later remains with a BMI of 29) and Marceau
Rabkin
4
3
published the first paper.
in September 1999 did the first hand-assisted LDS (Laparoscopic
DS) and Gagner et al
5,6
the first totally laparoscopic LDS in October of the
same year. Gagner et al 7 published the first report of the LSG (Laparoscopic
SG) as the first stage of the LDS in the super-obese patients.
Matherial & Methods:
Thirty-one obese patients have been treated with the LSG (selected from a
total of 791 patients who had the DS) from Jan 2003 until June 2005, for
different conditions:
I)
Super-obese (SO). Seven patients had, BMI ranging from 61
to 74 (mean 65), the LSG as a first stage of the full LapDS. One patient
had a previous Lap fundoplication and has the Nissen dismounted at
the time of the LSG.
II)
Severe medical illness and BMI > 40. Seven patients had a
severe medical condition that made not advisable the full DS. Four
had unexpected cirrhosis of the liver (discovered at surgery and later
confirmed by biopsy), one BMI-51 patient had Crohn´s disease and a
4
previous right hemicolectomy, one BMI-60 patient had a severe
pulmonary poisoning condition (Ardystil syndrome) and one BMI-61
patient is a HIV+ without AIDS
III)
Low BMI. Sixteen patients had BMI from 35 to 43 with at
least one co-morbidity, and
IV)
Conversion from a Lap-band. A patient with normal BMI
had severe unbearable symptoms that required conversion.
Technique: General anesthesia is given. The drawing of the operation is
shown in Fig 1. An Endopath gasless technique is used to enter the abdomen by
a #12 mm. trocar on the supraumbilical lateral border of the right rectus. Four
more #5 mm trocars were placed 1) subxifoid, 2) right costal margin, 3) left
costal margin, 4) lateral border of the left rectus and a #10 mm. trocar for the
camera in the midline (Fig.2). Bupivacaine is used as local anesthetic at all the
trocar entrances.
Division of the greater curvature of the stomach is done with the HS
(Harmonic scalpel) from the left crus of the diaphragm to distal to the pylorus.
At the level of the spleen’s lower pole, the peritoneal sheets are farther apart and
the tissue in between is thicker and harbours tortuous vessels (the short gastric)
which must be coagulated separately by using small bites of the HS.
Two sequential USSC (Tyco Healthcare) 45 mm. blue linear staplers are used
starting 2 cm from the pylorus, and close to a 32 F naso-gastric tube, up to the
incisura angularis. Then the Tyco staplers 6 cm long are used (3 to 4) up to
reach the angle of His. A gastric tube (sleeve), less than 60 cc in volume,
remains and the rest of the 80% of the stomach is excised. The staple line is
5
inverted by placing a sero-serosa continuous suture of PDS from the angle of
His to mid-suture line and a second one to the end.
Diluted half-strength Methidine blue dye, 50 cc, is used to test for leaks. The
duodenum is clamped and by irrigating the sleeve the dye usually overflows
back to the patient’s mouth.
The stomach is removed by enlarging the peritoneal and fascial opening of the
#12 mm. trocar and pulling from the antrum without the need for a protecting
bag. The enlarged fascial opening is closed with a single figure-of-eight Maxon
#1 suture and a drain is left, through one #5 mm. port, for 2 days along the
pouch suture-line. Mean average operating time is 49 minutes (40 to 60) for the
<BMI-60 patients.
On POD1 the patient is given a test of oral Methidine blue dye and a
gastrografin x-ray study to rule out leaks and discharged on the POD2. Small
sipping, strictly liquids, oral feedings are used for 2 weeks and then they resume
normal intake.
Post-Op Dietary: It is imperative that SG patients adhere to a strict
postoperative diet. After 4-6 weeks, patients graduate to a 600-800 calorie/ day
solid diet. Once goal weight is achieved, usually 1-2 years after surgery, most
patients can consume about 1000-1200 calories per day.
Results:
For WL (Weight Loss) measures we have used the formula %EWL (percentage
of Excess Weight Loss) = [(Operative Weight – Follow-up Weight) / Operative
Excess Weight] x 100 and the %EBMIL (percentage of Excess BMI Loss) =
%EBMIL = 100 – [(Follow-up BMI – 25 / Beginning BMI -25) x 100]
6
I.
SO Patients. One male patient, BMI-74, with several co-
morbidities died due to complications related to the working port
hemorrhage. The rest of patients had a mean 56.1 %EWL (46-66%) and a
63.1 %EBMIL (57 to 72) from 4 to 27 months. Only one BMI-62 patient
had, one year later, a second stage of the DS at BMI-49 and, now six
months later her BMI is 33.
II.
Severe medical illness and BMI > 40. The patient with Crohn’s
disease has at 16 months a %EWL 0f 59.5 and %EIMCL = 66.0. The patient
with the pulmonary condition has at 14 months %EWL = 72.5 and her
%EIMCP = 76.0. The HVI+ patient at 4 months has %EWL=33.6 and
%EIMCL=36.8. The cirrhotic patients have 71 %EWL (64-90) and 76
%EBMIL (69-100) without worsening their liver function.
III.
Low BMI patients. One patient ruptured (while coughing) the
sutured working trocar access and developed an intra-abdominal bleeding
that required re-laparoscopic aspiration of 400 cc. hemoperitoneum and
suture of the abdominal opening again. The patients have a %EWL at 3-27
months of 62.3 %EWL (42-100) and 68.5 %EBMIL (58-123%).
IV.
Conversion from a Lap-band. The only patient had a BMI of 28
and her BMI is 27 one year later, %EBMI 13%, and her QOL was improve
significantly.
Two patients suffered serious complication of trocar related intrabdominal
bleeding, one of then died (3.2% mortality) and the second required
laparoscopic exploration. No episodes of deep venous thrombosis, pulmonary
emboli, pneumonia, acute respiratory distress syndrome, splenectomy, gastric
leak and fistula or small bowel obstruction occurred.
7
All these patients have done clinically extremely well at the intermediate
period. None of them had any pernicious side-effect. Early satiety has been their
only symptom. B12 and folic acid have been normal. None of them have anemia.
Two patients with hypertension and diabetes are off medications.
Discussion:
Hess
1, 2
after 10 years follow up with a %EWL of 75% in 94% of his patients
considers that the DS is the most effective operation and should become the
gold standard in bariatric surgery and we, as Rabkin 8, fully agree with him.
The idea of the SG appeared after the LDS became a reality. The LSG has been
proposed as a first step in the staging of the LapDS
9,10,11,12
by different authors
with encouraging results for high >55 BMI patients.
Staging helps decrease mortality mostly in the association of Super-SuperObesity and male gender were the mortality is elevated in patients undergoing
the DS procedure
13,
but even LSG resulted in mortality in our male super-
super-obese with a minor trocar site hemorrhage.
To protect the stomach suture line from bleeding and leaks other materials
have been added (buttressed absorbable polymer membranes, Goretex, bovine
pericardial strips, etc.) with mixed results 14, 15, 16. We use a continue absorvable
suture sero-serosa, inverted over the staples, which controls bleeding in almost
all cases, decrease leaks 1, does no increase the cost of the procedure and takes
about 10 minutes of suturing.
LSG generates weight loss by restricting the amount of food that can be eaten
without any malabsorption. The stomach pouch in the LSG is usually made
smaller than the pouch that DS patients because without an intestinal bypass
8
weight regain may happens as in the gastroplasty procedures done in the 1970's
and 80's. Basically, the SG is an improvement over prior gastroplasty
procedures, which today are rarely done due to problems related to the
placement of staples, silastic rings and mesh around the stomach pouch and
reservoir-gastric fistulas. No foreign body is used as it is on the vertical banded
gastroplasty and adjustable bands.
We do not think the M&M (Magenstrasse and Mill) operation described by
Johnston
17
is the same as a SG type of operation. On the M&M, The
Magenstrasse or “street of the stomach” is a long tube fashioned from the lesser
curvature, which conveys food from the esophagus to the antral Mill. Normal
antral grinding of solid foods and antro-pyloro-duodenal regulation of gastric
emptying and secretion are preserved. There is no resection of the stomach and
the antrum (Mill) is intact and the rest of the stomach is in the food pathway, so
the Ghrelin production is not reduced and food can enter the rest of the stomach
before it empties into the duodenum. It is also simple gastroplasty with leads to
a 60% EWL but more difficult to carry out by laparoscopy than the LSG. What
Johnston reports is the importance of the size of the NG tube stent while doing
the division of the stomach since the 32 F proved to be the ideal size for better
weight loss.
Consensus about the gastric sleeve volume is still to be made. Gagner et al
6
uses a 60F gastric bougie and the gastric volume is 150-200 cc. and this could
be a reason why some patients may require further surgery due to dilation of the
gastric pouch 18.
LSG patients at the Mt Sinai Hospital (NYC) have approximately 60 percent of
the stomach removed and patients get a %EWL of 30 to 50% of their excess
9
body weight over a 6 - 12 month period. Lee
10
removes about 85% of the
stomach in 68 patients. Schauer 11 uses a 48F bougie in his 77 patients.
The distance from the pylorus where the division of the stomach starts is not
standard. Gagner 7 recommends 10 cm, Lee 10 only 6 cm. We start the division of
the antrum 2 cm from the pylorus in the LSG and 3 to 4 cm on the LDS, because
the “restrictive only” SG should be more restrictive still than the full DS, since it
is the only mechanism used to loose weight. Our stomach remnant is reduced in
volume to less than 50 cc but functions normally and most foods can be
consumed, albeit in small amounts, and gastric emptying is normal 19,
20.
SG eliminates the portion of the stomach that produces the hormones that
stimulates hunger (Ghrelin). No dumping syndrome exists in the SG because
the pylorus is preserved and it minimizes the incidence of peptic ulcers. By
avoiding the intestinal bypass, the risk of intestinal obstruction (blockage),
anemia, osteoporosis, protein malnutrition and vitamin deficiencies are
eliminated. Very large, > 65 BMI patients can still be operated on.
LSG is also an appealing option for people with other medical conditions such
as existing anemia, those who need to take anti-inflammatory medications,
Crohn's disease and numerous other conditions that make them the DS too high
risky for intestinal bypass procedures.
For patients with low BMI (BMI 35-43 kg/m2), early and limited results
appear promising as a single stage procedure in our cases but follow up is still
too short. If the long-term results are maintained, this procedure may become
the ideal operation for those patients instead of the lap-band since no foreign
body is used, no adjustments are needed, and excess stomach volume is
removed, not left in place. This possibly eliminates most Ghrelin hormone
production and helps to reduce the sensation of hunger that obese patients
10
have. The patient also has a second opportunity to have the second stage part of
the DS if the WL results are not significant without the need to go back to the
upper abdomen to remove a problematic band. It seems to us at this time that
LSG is the best alternative to the lap-band for low BMI patients; those were the
lap-band has the best indications.
The LSG is also a good indication for the patients were the lap-band has given
complications such us poor weight lost, perforation and removal or poor QOL,
such as in our only patient who after removal of the band and LSG has improved
her QOL.
LSG disadvantages are: This procedure does involve stomach division and
stapling and therefore leaks and other complications related to stapling may
occur. Potential for inadequate weight loss or weight regain. While this is true
for all weight loss procedures, it is theoretically more likely with procedures that
do not have an intestinal bypass. Higher BMI patients will need to have a
second stage procedure later to help loose the rest of the excess weight if their
BMI remains above 45. Two stages may ultimately be safer and more effective
than one operation for high BMI patients. This is an active point of discussion
for bariatric surgeons. Soft calories such as ice cream, milk shakes, etc. can be
absorbed and may slow weight loss. Because the stomach is removed, it is not
reversible, but it can be converted to almost any other weight loss procedure,
mainly laparoscopic gastric bypass or DS. Long-term WL results are at this time
unknown but on the low BMI patients if 70% of them will have <50 %EWL this
will eventually be for them the ideal operation.
11
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