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Initial Outcomes Following Laparoscopic Sleeve Gastrectomy in 292 Patients as a Single-stage Procedure for Morbid Obesity

| February 18, 2010

by Alex Gandsas, MD, MBA, FACS; Christina Li, MD; Marvin Tan, MD; Adrian Barbul, MD

Dr. Gandsas is Professor of Surgery, Chair of the Department of Surgery, University of Medicine and Dentistry of New Jersey, School of Osteopathic Medicine, Stratford, New Jersey. Drs. Li, Tan, and Barbul are from Sinai Hospital of Baltimore, Baltimore, Maryland.

Bariatric Times. 2010;7(2):11–13

Financial disclosures:
Dr. Gandsas is a consultant for Ethicon Endo-Surgery, Covidien, and Synovis Surgical Innovations. Drs. Li, Tan, and Barbul have no financial disclosures

Laparoscopic sleeve gastrectomy is becoming an acceptable operation when it is chosen as a single stage procedure to treat patients suffering from morbid obesity. The present study evaluates our initial outcomes using this technique as a single-stage surgical approach for the treatment of morbid obesity.

We have conducted a retrospective review of 292 consecutive patients undergoing a single-stage laparoscopic sleeve gastrectomy from October 2006 to December 2009. The technique involved the use of linear staplers loaded with bovine pericardial strips and a 40 French bougie.

This study comprises 245 women and 47 men with a mean age of 42 years (range, 18–66 years), a mean body mass index of 49kg/m[2] (range, 35–88kg), and a mean weight of 301 pounds (range, 198–595 pounds). The mean follow up was seven months (range 1–24 months).

There were no conversions to laparotomy. The mean hospital stay was 1.7 days (range 1–4). One patient (0.3%) developed a trocar site infection, two patients (0.6%) suffered from postoperative bleeding, one patient (0.3%) suffered from deep venous thrombosis, and one patient (0.3%) was diagnosed with pulmonary embolism. One patient (0.3%) was diagnosed with a leak four months after surgery that required a laparoscopic surgical intervention with drainage of an intra-abdominal collection. No deaths were accounted in this study. The average percentage weight loss was 24 percent (n=233), 36 percent (n=174), 50 percent (n=127), 57 percent (n=81), and 60 percent (n=66) at 1, 3, 6, 9, and 12 months, respectively. Patients presenting with a preoperative body mass index lower than 50kg/m2 showed greater percentage of excess weight loss of 54 percent and 66 percent at 6 and 12 months, respectively, than those patients with a preoperative body mass index higher than 50kg/m2, 43 percent and 50 percent respectively (p<0.05). These data suggest that laparoscopic sleeve gastrectomy is a safe and effective treatment that results in significant weight loss at one year when offered as a single-stage procedure.

While obesity has achieved epidemic proportions, the surgical treatment for patients with morbid obesity has proven to be the most effective way to sustain weight loss and to improve most weight-related comorbidities.[1]

In addition to the most popular bariatric surgical procedures, such as the gastric bypass and the laparoscopic adjustable band, laparoscopic sleeve gastrectomy (LSG) has been added to the surgeon’s armamentarium as the first step of a stage approach for the surgical treatment of patients with morbid obesity and super-obesity with the aim of reducing the intra- and postoperative risk of morbidity and mortality.[2–3]

With several studies demonstrating the simplicity of the technique, lower operative times, and low complication rates, many have started to propose the LSG as a single-stage restrictive operation for not only patients with super-obesity suffering  from major comorbidities,[4] but also to those with a body mass index (BMI) of less than 50kg/m[2].[5]

Despite the vast experience worldwide with this procedure, it is interesting to see a lack of consensus as to the effectiveness as well as safety LSG offers to patients with morbid obesity.

In addition, the simple question of whether LSG can be offered as a single-stage approach to effectively control weight and improve comorbidities remains unanswered.

The purpose of this study is to present our experience in performing LSG as a single-stage approach for the treatment of morbid obesity and to evaluate its effectiveness during the first 12 months following surgery.

Material and Methods
This study was designed at a community hospital and was compliant with all Health Insurance Portability and Accountability (HIPPA) regulations. Between October 2006 and December 2009, a total of 292 patients underwent LSG as a single-stage approach for the treatment of morbid obesity. The study group consisted of 245 women and 47 men, with a mean age of 42 years, a mean body weight of 301 pounds (range: 195–595 pounds) and a mean BMI of 49kg/m[2] (range: 35–88kg/m[2]).

Patient selection resulted from a combination of patient preference among different bariatric procedures, discussions with the bariatric surgeon, and health benefits provided by the patient’s health insurance carrier.

Preoperative workup included blood test, cardiovascular assessment, sleep apnea studies, and an upper gastrointestinal contrast study. In addition, most patients (61%) underwent a six-month, supervised, low-carbohydrate diet conducted by our registered dietitian before undergoing surgery.

Patients were placed in supine position under general anesthesia. A single dose of 40mg of enoxaparin (Lovenox®, sanofi-aventis U.S. LLC, Bridgewater, New Jersey) was administered at induction while an orogastric tube was introduced to decompress the stomach.

The technique involves the insertion of a Verres needle in the left upper quadrant, followed by insufflation of the abdominal cavity to a pressure of 15mmHg. The abdominal cavity is then accessed through a 0.5cm left subcostal incision using the Optiview™ trocar  (Ethicon EndoSurgery, Cincinnatti, Ohio). Following this, under direct vision, two 12mm ports are introduced lateral to the umbilicus approximately 15cm from the xifoid, followed by another two 5mm ports in the right upper quadrant and one 5mm port lateral to the left rectus fascia. A 45-degree laparoscope was introduced through the left 12mm port. A flexible liver retractor (Mediflex Surgical Products, Islandia, New York) was inserted from the left side to lift up the left lobe of the liver. A 40 French bougie replaced the orogastric tube and was used to size the gastric sleeve as well as to help prevent strictures during the sleeve gastrectomy. Dissection started at the level of the gastrocolic ligament, which is excised 6cm proximal to the pylorus, exposing the lesser sac and posterior stomach. This dissection continued by dividing all vessels along the major curvature using the Harmonic™ Scalpel (Ethicon EndoSurgery, Cincinnatti, Ohio), including the short gastric vessels, thus, disengaging the fundus from the splenic capsule completely exposing the left crura (Figure 1). A vertical gastrectomy was then carried out by transecting the stomach using multiple fires of a 60mm linear cutting stapler. (Echelon® 60™, Ethicon, EndoSurgery, Inc., Cincinnatti, Ohio) reinforced with bovine pericardium (Peristrips Dry™, Synovis Surgical Innovations, St. Paul, Minnesota) (Figure 2). This maneuver started on the greater curvature at 6cm proximal to the pylorus and continued toward the angle of Hiss by applying multiple fires, alongside the bougie. The first two fires involved a green load stapler (4.1mm) followed by 4 to 5 fires of a yellow load stapler (1.8mm, Echelon, Ethicon EndoSurgery, Inc). Once the stomach was completely divided, the bougie was removed and the specimen retrieved from the abdominal cavity through one of the 12mm port sites. The fascia of this enlarged site is then closed with a single absorbable suture (2/0 Vicryl). A leak test was not usually performed. Once hemostasis was verified, all ports were removed without draining the abdominal cavity.

During the first postoperative day, the patients were placed on liquids-per-oral, once an upper gastrointestinal contrast study failed to demonstrate evidence of leakages. Follow-up assessments took place at 1, 3, 6, 9, and 12 months postoperatively.

There were no conversions to laparotomy. The mean hospital stay was 1.7 days (range 1–4 days). One patient (0.3%) developed a trocar site infection, one patient (0.3%) suffered from deep venous thrombosis, and one patient (0.3%) was diagnosed with pulmonary embolism. One patient (0.3%) was diagnosed with a leak four months after surgery, required a laparoscopic surgical intervention with drainage of an intra-abdominal collection. There were no perioperative deaths accounted in this study. Two patients (0.6%) suffered from postoperative bleeding that required re-intervention in one of them. The average percentage weight loss was 24 percent (n=233), 36 percent (n=174), 50 percent (n=127), 57 percent (n=81), and 60 percent (n=66) at 1, 3, 6, 9, and 12 months, respectively (Table 1). When the data is broken down in two groups based on pre-operative BMI, patients with BMI between 35 and 49kg/m[2] showed greater weight loss at six months(54%) and 12 months (66%) than patients with preoperative BMI above 50kg/m[2]. (43% and 50% respectively, p>0.05). (Table 2) The mean follow up was seven months (range 1–24). The mean operative time was 89 minutes (range: 45–120 minutes).

During the first month, nine patients had to be readmitted to the hospital due to dehydration, nausea, and vomiting. One patient presented symptomatic choleliathisis at nine months follow up and underwent a cholecystectomy.

LSG is considered by many authors a modification of the original Magenstrasse and Mill operation.[6] It is a relatively less complex operation that yields a significant weight loss, especially when combined with a malabsorption operation, such as the duodenal switch or gastric bypass.[7,8]

Several authors have noted the benefits of offering the LSG not only as a staged procedure,2 but also as a single-stage approach to patients suffering from several comorbidities with a high intraoperative risk, particularly in the super and morbidly obese population.[9]

Although the actual mechanism from what LSG results in weight loss is still debatable, several studies have shown that, in addition to its restrictive mechanism to food intake, due to limited distensibility, weight loss is also achieved by reducing the levels of ghrelin hormone, primarily generated in the gastric fundus.[10,11]

At the beginning of our series, we started using a 44F bougie, but quickly migrated to a 40F once we became more comfortable with the technique. Although we did not look at the correlation between bougie sizes and weight loss, we agree with the study by Parikh et al[12] that concluded that variation in bougie sizes does not result in weight loss differences, at least in the short term.[12] A major risk of utilizing a lower size bougie is the concern of causing an iatrogenic stricture.[13]

We also try to start the division of the vascular supply of the major curvature with the first application of the endostapler no closer than 5 to 6cm from the pylorus. There is still debate whether the gastric antrum should remain intact to preserve its “pumping” capabilities[14,15] as well as to avoid gastric emptying problems.[16,17]

Several studies[1,13] have reported gastric leaks and postoperative bleeding as the most common complications following laparoscopic gastric bypass. Using buttressing reinforcement for the staple line has been shown to be advantageous as reported by Shikora et al.[18] In our study we opted to incorporate bovine pericardium buttressing material in all staple lines while performing sleeve gastrectomy. We have only experienced one postoperative leak that occurred at four months following surgery after the patient developed an infected hematoma that required computed tomography-guided drainage. It is not clear whether the hematoma, with its subsequent abscess, or the insertion of drain were responsible for this event. Although we did not notice major intraoperative bleeding from the staple lines when reinforced with bovine pericardium, we do account for two patients who developed postoperative bleeding. One of them suffered, from protein C and S deficiency for which he received aggressive postoperative doses of enoxaparin (150mg, twice a day) to reduce his risk for strokes.

In our series, we have also offered the gastric sleeve to 22 patients who presented with a very high surgical risk from the cardiovascular stand point. Specifically, because of this cardiac history we chose not to discontinue their daily dose of aspirin (81mg/day) and we proceeded with surgery. There was no bleeding event in any of this patient group during the immediate postoperative period, suggesting that the use of NSAID and aspirin may be safe during laparoscopic sleeve gastrectomy.

In summary, our data suggest that LSG is a safe and effective treatment that results in significant weight loss at one year when offered as a single-stage procedure in particular for patients whose BMI is lower than 50kg/m[2]. Further studies are necessary to address weight regain, sleeve dilatation, malnutrition, and the impact on comorbidities.

1.    Maggard MA, Shugarman LR, Suttorp M, et al. Meta-analysis: Surgical treatment of obesity. Ann Intern Med. 2005;142(7):547–559.
2.    Cottam D, Qureshi FG, Mattar SG,  et al. Laparoscopic sleeve gastrectomy as an initial weight-loss procedure for high-risk patients with morbid obesity. Surg Endosc. 2006;20(6):859–863.
3.    Mognol P, Chosidow C, Marmuse JP. Laparoscopic sleeve gastrectomy as an initial bariatric operation for high-risk patients: Initial results in 10 patients. Obes Surg. 2005;15:1030–1033.
4.    Regan JP, Inabnet WB, Gagner M, et al. Early experience with two-stage laparoscopic Roux-en-Y gastric bypass as an alternative in the super obese patient. Obes Surg. 2003;13:861–864.
5.    Tucker ON, Szomstein S, Rosenthal RJ. Indications for sleeve gastrectomy as a primary procedure for weight loss in the morbidly obese. J Gastrointest Surg. 2008;12(4):662–667.
6.    Johnston D, Dachtler J, Sue-Ling HM, et al. The Magenstrasse and Mill operation for morbid obesity. Obes Surg. 2003;13(1):10–16.
7.    Gumbs A, Gagner M, Dakin G, et al. Sleeve gastrectomy for morbid obesity. Obes Surg. 2007;17:962–969.
8.    Baltasar A, Serra C, Perez N, et al. Laparoscopic sleeve gastrectomy: a multi-pupose bariatric operation. Obes Surg. 2005;15:1077–1081.
9.    Givon-Madhala O, Spector R, Wasserberg N, et al. Technical aspects of laparoscopic sleeve gastrectomy in 25 morbidly obese patients. Obes Surg. 2007;17:722–727.
10.    Langer FB, Reza Hoda MA, Bohdjalian A, et al. Sleeve gastrectomy and gastric banding: effects on plasma ghrelin levels. Obes Surg. 2005;15(7):1024–1029.
11.    Kotidis EV, Koliakos G, Papavramidis TS, Papavramidis ST. 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? Obes Surg. 2006;16(5):554–559.
12.    Parikh M, Gagner M, Heacock L, et al. Laparoscopic sleeve gastrectomy: does bougie size affect mean %EWL? Short-term outcomes. Surg Obes Relat Dis. 2008;4(4):528–533.
13.    Eubanks S, Edwards CA, Fearing NM, et al. Use of endoscopic stents to treat anastomotic complications after bariatric surgery. J Am Coll Surg. 2008;206(5):935–938; discussion 938–939.
14.    Goitein D, Goitein O, Feigin A, et al. Sleeve gastrectomy: radiologic patterns after surgery. Surg Endosc. 2009 Feb 27.
15.    Treacy PJ, Jamieson GG, Dent J. The importance of the pylorus as a regulator of solid and liquid emptying from the stomach. J Gastroenterol Hepatol. 1995;10(6):639–645.
16.    Weiner RA, Weiner S, Pomhoff I, et al. Laparoscopic sleeve gastrectomy—influence of sleeve size and resected gastric volume. Obes Surg. 2007;17(10):1297–1305.
17.    Bernstine H, Tzioni-Yehoshua R, Groshar D, et al. Gastric emptying is not affected by sleeve gastrectomy—scintigraphic evaluation of gastric emptying after sleeve gastrectomy without removal of the gastric antrum. Obes Surg. 2009;19(3):293–298.
18.    Shikora SA, Kim JJ, Tarnoff ME. Comparison of permanent and nonpermanent staple line buttressing materials for linear gastric staple lines during laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2008;4(6):729–734.

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