Surgical Endoscopy

, Volume 26, Issue 3, pp 831–837

Laparoscopic sleeve gastrectomy for obesity: can it be considered a definitive procedure?

Authors

    • Department of Surgery, Jacobi Medical CenterAlbert Einstein College of Medicine
  • Edward Chao
    • Department of Surgery, Jacobi Medical CenterAlbert Einstein College of Medicine
  • Yana Etkin
    • Department of Surgery, Jacobi Medical CenterAlbert Einstein College of Medicine
  • Lynn Merklinger
    • Department of Surgery, Jacobi Medical CenterAlbert Einstein College of Medicine
  • Jayne Lieb
    • Department of Surgery, Jacobi Medical CenterAlbert Einstein College of Medicine
  • Harry Delany
    • Department of Surgery, Jacobi Medical CenterAlbert Einstein College of Medicine
Article

DOI: 10.1007/s00464-011-1960-2

Cite this article as:
Chopra, A., Chao, E., Etkin, Y. et al. Surg Endosc (2012) 26: 831. doi:10.1007/s00464-011-1960-2

Abstract

Background

Providing bariatric surgery services to an inner-city population is a challenge. Laparoscopic sleeve gastrectomy (LSG) is an effective operation for morbid obesity with a relatively low complication rate. LSG appears to be a suitable alternative procedure for this group of patients.

Methods

This is a retrospective review and analysis of the experience with 185 consecutive LSGs that had completed at least 6 months follow-up. Eleven conversions from LSG to laparoscopic Roux-en-Y gastric bypass were excluded, leaving 174 patients for outcome analysis. Data collected were patient demographics, body mass index (BMI), comorbid conditions, operating time, length of hospital stay, and perioperative complications. Weight loss and resolution/improvement of comorbidities were analyzed.

Results

Mean patient age was 39.58 years and mean BMI was 48.97 kg/m2. The percentage of patients with BMI > 50 kg/m2 was 37.94%. Mean excess weight loss (EWL) was 44.76, 55.52, 59.22, and 58.92% at 6, 12, 24, and 36 months, respectively. Six patients (3.24%) lost less than 25% EWL. Thirteen patients (7.02%) regained an average of 13 lb after reaching a plateau. Resolution/improvement of comorbidities was 84% for diabetes mellitus, 49.99% for hypertension, 90% for asthma, 90.74% for obstructive sleep apnea, and 45.92% for gastroesophageal reflux disease symptoms (GERD). The mortality rate was zero in this series. Perioperative complications occurred in 26 patients (14.05%): four staple-line leaks (2.16%), four bleeds (2.16%), four obstructions (2.16%), five vomiting/dehydration (2.70%), six new onset of GERD symptoms (3.24%), two with pneumonia (1.08%), and one with pulmonary embolism (0.54%).

Conclusion

LSG results in stable and adequate weight loss with resolution/improvement in comorbidities in a high percentage of patients. It can be considered a definitive operation for morbid obesity.

Keywords

Laparoscopic sleeve gastrectomyPerioperative complicationsExcess weight lossComorbiditiesGastroesophageal reflux disease (GERD)

As the number of bariatric surgical procedures continues to increase worldwide, surgeons have been evaluating newer procedures to lower long-term morbidity. Laparoscopic sleeve gastrectomy (LSG) has had increasing popularity over the last few years due to its simplicity and safety. Sleeve gastrectomy was first described in 1988 when Scopinaro’s technique of biliopancreatic diversion (BPD) with distal gastrectomy and gastroileostomy was modified by Hess to a sleeve gastrectomy and duodenal switch (BPD-DS) [1]. Gagner [2] described the first laparoscopic BPD-DS in 1999. In order to reduce the complication rate seen with this approach, he introduced the concept of utilizing LSG as an initial procedure in super-super morbidly obese patients. It was found that LSG alone resulted in good weight loss. At the same time, results from the Magenstrasse and Mill (MM) procedure, a modification of vertical banded gastroplasty (VBG), were published, with a mean percentage weight loss of 60% with follow-up of 1–5 years [3]. Although similar in concept to the MM procedure but with an additional gastric resection, there was growing interest in LSG as a standalone procedure. In an updated position statement on LSG published by American Society of Metabolic and Bariatric Surgery (ASMBS) Clinical Issues Committee, 36 studies had reported on a total of 2,570 patients with a mean weight loss of 55% (range = 33–85%) and resolution of comorbidities comparable to those seen with other bariatric procedures [4]. Despite the promising results seen at short and medium follow-up periods, long-term results for this procedure are lacking, with only a few studies reporting durable weight loss at 5–6 years [57].

In addition, some specific questions remain unanswered. Can this procedure be recommended as a definitive weight loss operation for all obesity classes and age groups? Does this operation lead to resolution or induction of acid reflux symptoms? What is the incidence of inadequate weight loss or weight regain? This report describes a standardized technique, analysis of our data, and an attempt to answer these important questions.

Materials and methods

This article describes the patients who underwent LSG since June 2006 at Jacobi Medical Center, Bronx, NY. Of a total of 260 cases done between June 2006 and December 2010, this study is a retrospective analysis of 185 consecutive cases that had completed at least 6 months follow-up. Patients were offered this procedure as an alternative to laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic adjustable gastric banding (LAGB), with an understanding that the long-term data on weight loss for this procedure are not yet available. For patients with BMI > 60 kg/m2, predominantly central obesity, extensive previous surgery, and multiple comorbid conditions, LSG was recommended as a preferred approach. Patients had a thorough preoperative evaluation that included upper gastrointestinal endoscopy, upper gastrointestinal imaging, right-upper-quadrant abdominal sonography, and psychological and medical evaluations. For the diagnosis of obstructive sleep apnea (OSA), patients underwent a sleep study if the patient scored more than 12 on the Epworth Sleepiness Scale [8]. Cardiopulmonary evaluation was undertaken when indicated. The data were collected in a Microsoft Excel® spreadsheet, which included patient demographics, preoperative weight, height, BMI, operating time, and comorbid conditions. Presence of preoperative acid reflux symptoms, its severity, and frequency were recorded. The ideal body weight was calculated using the Metropolitan height-and-weight table using the midpoint of the medium frame weight [9]. Patients were scheduled for follow-up at 1 week, then at 1, 3, 6, and 12 months and yearly thereafter. The weight loss was expressed as percent excess weight loss (%EWL). Inadequate weight loss was defined as %EWL of less than 25%. The status of comorbid conditions and complications were recorded. Resolution of diabetes mellitus (DM) was defined as cessation of antidiabetes medications by the primary care physician or by an HbA1c level of <7%. Resolution of hypertension (HTN) or asthma was defined as discontinuation of medications by the primary care physician. Resolution of sleep apnea was defined as the discontinued need for continuous positive airway pressure (CPAP) machine use.

The results were expressed as mean ± standard deviation. Statistical evaluations were performed using unpaired Student’s t-test. Statistical significance was set at P < 0.05.

Surgical technique

The patient is placed in a supine position on the operating table. The lower extremities are supported and secured with a belt and tape. The feet are supported with a foot board. Pneumoperitoneum is insufflated with a Veress needle in the left-upper-quadrant/subcostal area. The operation is generally performed with four trocars (Ethicon Endo-Surgery, Cincinnati, OH): two 5 mm, one 12 mm, and one 15 mm. The trocar placement sites are shown in the Fig. 1. The liver is retracted with a Nathanson retractor (Cook Medical Inc., Bloomington, IN) placed through an incision in the subxiphoid area. The patient is then placed in a steep reverse Trendelenburg position to start the procedure. We enter the lesser sac by dividing the omental attachments to the greater curvature of the body of the stomach using a Harmonic scalpel (UltraCision, Ethicon Endo-Surgery). This division is kept close to the stomach wall thus avoiding gastroepiploic vessels. The fundus of the stomach is mobilized from the spleen by dividing the gastrosplenic ligament with short gastric vessels. Care is taken to mobilize the upper part of the fundus completely from the left crus of the diaphragm. Distally, omental division is continued to a point about 5 cm from the gastroduodenal junction. A 34-Fr stomach tube is then advanced along the lesser curvature pointing toward the pylorus. The stomach sleeve is constructed around this tube using a linear roticulating stapler with a 60 mm cartridge (Echelon, Ethicon Endo-Surgery). Two green cartridges are used (4.1 mm) for the antrum and distal body of the stomach, one gold cartridge (3.8 mm) for the upper body of the stomach, followed by two to three blue cartridges (3.5 mm) for the fundus. We routinely use SeamGuard® (W.L. Gore & Associates Inc., Newark, DE) staple-line reinforcement strips to reduce staple-line bleeding (Fig. 2). Care is taken not to leave excess fundus while fashioning the proximal sleeve resection margin. Figure-of-eight sutures are placed at any crossing staple lines. The resected stomach is removed through the stretched 15 mm umbilical port site. The patients are admitted to a monitored unit postoperatively. All patients undergo an upper gastrointestinal Gastrografin®/barium study on postoperative day 1. After a negative leak result, patients are started on clear, sugar-free liquids. Patients are discharged on postoperative day 2 with instructions to start a full liquid sugar-free low-fat diet.
https://static-content.springer.com/image/art%3A10.1007%2Fs00464-011-1960-2/MediaObjects/464_2011_1960_Fig1_HTML.jpg
Fig. 1

Our standard port placement for LSG

https://static-content.springer.com/image/art%3A10.1007%2Fs00464-011-1960-2/MediaObjects/464_2011_1960_Fig2_HTML.jpg
Fig. 2

Remnant stomach after construction of the sleeve

Results

Two hundred sixty LSGs were performed between June 2006 and December 2010 at Jacobi Medical Center, Bronx, NY. We have included 185 consecutive cases that had completed at least 6 months follow-up. Eleven conversions to LRYGB were excluded, thus leaving 174 patients for outcome analysis. There were 149 (85.63%) women and 25 (14.37%) men in this group. The age ranged from 18 to 64 years (mean age = 39.58 ± 10.71 years). Mean preoperative body weight was 287 ± 60.81 lb (range = 186–524 lb). The mean body mass index (BMI) was 48.97 ± 8.25 kg/m2 (range = 35–77.3), with 37.94% patients (n = 66) considered super obese. Mean follow-up was 16 ± 8.96 months. Patient demographics are given in Table 1. All procedures were completed laparoscopically. In all but four patients, LSG was the first bariatric operation. The other four were conversions from laparoscopic gastric banding (LAGB). Mean operating time was 103.9 min (range = 40–270). Mean length of hospital stay was 2.6 days (range = 2–25). There was no mortality.
Table 1

Patient demographics

Characteristic

Total No. (%)

Mean (±SD)

Range

Total No. of patients

185

 

 

No. of patients without conversion to LRGB

174

 

 

Female

149 (85.63)

 

 

Male

25 (14.37)

 

 

Superobese (BMI > 50)

66 (37.94)

 

 

Length of follow-up (months)

 

16 (8.96)

6–36

Age (years)

 

39.59 (10.71)

18–64

Height (in.)

 

64.03 (3.33)

57–75

Weight (lb)

 

287.4 (60.81)

186–524

BMI (kg/m2)

 

48.97 (8.25)

34.5–77.3

Perioperative complications (Fig. 3) occurred in 26 patients (14.05%). There were four leaks (2.16%), all located near the proximal end of the staple line. Two leaks were detected on postoperative day 1 and were successfully closed with laparoscopic suture repair. The other two were delayed at postoperative day 6 and 19. The operative repair for the leak at postoperative day 6 failed and was then managed with placement of a covered endoesophageal stent. The leak at 19 days was successfully treated with parenteral nutrition and antibiotic therapy.
https://static-content.springer.com/image/art%3A10.1007%2Fs00464-011-1960-2/MediaObjects/464_2011_1960_Fig3_HTML.gif
Fig. 3

Perioperative complications

Bleeding was encountered in four patients (two intraoperative, two postoperative) (2.16%). The postoperative bleeds required blood transfusion. None of the patients in this group required operative intervention. Four patients (2.16%) developed gastric obstruction. All but one obstruction was seen near the incisura angularis. The fourth patient had a narrowing in the proximal part of the sleeve. They were all managed with revision to LRYGB. Two patients (1.08%) developed pneumonia and one (0.54%) had pulmonary embolism. Five patients (2.70%) were admitted postoperatively with persistent nausea, vomiting, and dehydration. All improved with intravenous hydration and were discharged. Six patients (3.24%) complained of new onset of gastroesophageal reflux disease (GERD) symptoms.

Mean %EWL was 44.76 ± 11.91, 55.52 ± 17.59, 59.22 ± 18.26, and 58.92 ± 21.63% at 6 months and 1, 2, and 3 years, respectively (Table 2). Median weight loss was similar. Six patients (3.24%) lost less than 25% EWL. Thirteen patients (7.02%) regained an average of 13 ± 11 lb (range = 3–29 lb) after reaching a plateau.
Table 2

Percent excess weight loss (%EWL)

Time after operation (months)

Mean %EWL (±SD)

6 (n = 134)

44.76 (11.91)

12 (n = 118)

55.52 (17.59)

24 (n = 68)

59.22 (18.26)

36 (n = 12)

58.92 (21.63)

Analysis of our data defined weight loss differences between obese and super-obese patients as well as those less or more than 40 years of age. As is evident from Table 3, patients with BMI < 50 kg/m2 lost 7–10% more %EWL than those with BMI > 50 kg/m2. This was statistically significant at 6 and 12 months but not at the 24-month follow-up. Average age was similar in the two groups at different time intervals. Table 4 shows weight loss in two different age categories. Although %EWL difference was not statistically different at 6 months, patients less than 40 years old lost a mean of 6 and 11% more %EWL at 1 year and 2 years, respectively. Average BMI was similar in both groups at different time intervals.
Table 3

Differences in %EWL based on preoperative BMI

 

Mean %EWL (±SD)

Average age (years) (±SD)

Time after operation (months)

BMI < 50

BMI > 50

P

BMI < 50

BMI > 50

P

6

48.35 (11.56)

38.33 (9.6)

0.0000005

39 (11)

37 (10)

0.27

12

59.4 (17.91)

49.43 (15.36)

0.0017

39 (10)

38 (9)

0.54

24

61.47 (19.25)

54.83 (15.59)

0.13

40 (10)

38 (10)

0.42

Table 4

Difference in %EWL based on preoperative age

Time after operation

(months)

Mean %EWL (± SD)

Average initial BMI (± SD)

<40 years old

>40 years old

P

<40 years old

>40 year old

P

6

45.68 (13.06)

43.78 (10.56)

0.35

49.72 (8.33)

47.4(7.75)

0.09

12

58.72 (13.37)

52.21 (16.23)

0.043

51.07 (9.23)

47.82 (7.91)

0.04

24

65.03 (15.81)

54.06 (18.93)

0.011

49.61 (7.98)

47.19 (7.15)

0.19

Resolution or improvement of major comorbid conditions is shown in Table 5. Resolution of DM and HTN was noted in 33 and 26.66%, respectively, while improvement was seen in 51 and 23.33%, respectively. Asthma resolved in 32% but significantly improved in 58%. The majority of patients (90.74%) with OSA were either significantly improved or completely resolved.
Table 5

Resolution of comorbidities

Comorbidities

Total No. preop

Improved (%) (n)

Resolved (%) (n)

HTN

60

23.33 (14)

26.66 (16)

Diabetes

45

51 (23)

33.0 (15)

Asthma

50

58 (29)

32.0 (16)

Sleep apnea

31

67.74 (21)

23.0 (7)

GERD

24

16.66 (4)

29.16 (7)

HTN hypertension, GERD gastroesophageal reflux disease

Of a total of 24 patients with significant acid reflux symptoms present preoperatively, 11 (45.92%) had their symptoms resolved or improved. Acid reflux symptoms became worse in five patients (20.83%) and in 8 (33%) they remained the same. An additional six patients developed new onset of GERD symptoms. A total of six patients, four from the new-onset group and two from the group where preexisting symptoms got worse, were managed with conversion to a LRYGB with complete resolution of GERD symptoms. All the other patients were successfully treated with medical therapy.

Of the 11 conversions from LSG to LRYGB, 6 were for refractory GERD symptoms, four were for obstruction, and one was done to achieve more weight loss for further improvement of diabetes.

Discussion

Obesity has reached epidemic proportions globally. According to the WHO, about 1.7 billion adults are overweight (BMI > 25 kg/m2) and about 30% of these are obese (BMI > 30 kg/m2) [10]. In the United States, the incidence of obesity has steadily increased over the past few decades [11]. The prevalence of obesity has been noted to be higher in poor communities [12]. In the borough of the Bronx in New York City, with its high indigent population, the percentage of adults who are overweight or obese is 68% compared to 59.3% for the entire New York State [13]. It has been shown that patients with low family income and low education level have limited access to medical services, including bariatric care [14]. This potentially leads to obesity-related comorbid conditions like DM and HTN remaining undiagnosed or undertreated for prolonged periods of time, thus resulting in more severe and multiple medical conditions at the time of bariatric intervention. Given these facts, providing bariatric surgery services in this population has proved to be a continuous challenge. The need for close follow-up after bariatric surgery is of paramount importance and this follow-up is made difficult mainly due to the myriad of complex socioeconomic issues. The problems include frequent change of residence, change or loss of jobs, and discontinuation of telephone services. LRYGB needs lifelong surveillance because of the potential for long-term complications such as internal hernia, anemia, and bone changes [1517]. LAGB, although a simpler and safer procedure than LRYGB, requires frequent visits for band adjustment for optimal results [18]. This has been difficult to achieve in our patient population. Due to these issues, we elected to offer LSG to our patients as an alternative. LSG has the potential for lower complication rates and less long-term nutritional consequences. With excellent results obtained from LSG in the beginning of this experience, we observed an increasing preference for this procedure by our patients. Many patients initially interested in LRYGB or LAGB changed their selection to LSG. Increasing interest in LSG by the patients and surgeons alike has resulted in a number of studies published on this subject attesting to its effectiveness as a definitive bariatric procedure. This has been well summarized in the updated position statement published by ASMBS [4].

Until more recently, success or failure of a bariatric procedure was defined only by the total amount of weight loss, with several investigators suggesting that %EWL from 15 to 50% was a successful procedure [19, 20]. It was soon realized that the reporting of resolution/improvement of comorbidities and improved quality of life (QOL) was as important in determining the results of a bariatric procedure. This led to the development of the Bariatric Analysis and Reporting Outcome System (BAROS) [21]. We have assessed the %EWL and resolution/improvement of comorbidities and weight regain after LSG to define its success.

Percentage EWL in our patient cohort at different periods of follow-up appears to be comparable to that of most other studies examining similar parameters [5, 22, 23]. We observed maximum weight loss in the first 6 months, leveling off at 1 year in the majority of cases. Weight loss has remained stable up to 3 years in our patients. In our series, six patients lost less than 25% of %EWL. Limited weight regain was observed in 13 patients, with follow-up from 1 to 3 years. Long-term data on weight loss has been reported in a few recent studies. Bohdjalian [5] reported a mean EWL of 55% at 5 years, with weight regain in 19.2%. Himpens [7] published 6+ year results on weight loss on a subgroup of 30 patients. Weight loss was still satisfactory at 53.3%. Despite weight regain reported between the third and sixth year, the median BAROS score remained “good.” D’Hondt [6] reported 23 patients at 6 years follow-up with an EWL of 55.9% with “good” to “excellent” BAROS score in 90% of patients. Based on these data, it appears that despite weight recidivism, weight loss continues to be satisfactory over the long term. This compares favorably with weight loss results of LRYGB, where regain of weight in 20–50% patients has been reported [24, 25].

In this study, we found that super-obese patients had significantly less weight loss than morbidly obese patients. This finding has also been reported by other authors [22, 26]. Furthermore, patients under 40 years of age had a superior weight loss result. Although it may not be significant from the point of view of comorbidity resolution or improvement in QOL, we believe it is nonetheless important to discuss this with the patients preoperatively to avoid unrealistic expectations from the procedure. In addition, a small proportion of these patients may require alternative procedures, like LRYGB, to achieve more weight loss.

In terms of resolution of comorbid conditions, DM, HTN, asthma, and OSA resolved or improved in a majority of cases, attesting to the effectiveness of LSG as a definitive bariatric procedure. In our series, resolution rate for diabetes was 33%, whereas in 51% of patients, improvement without complete resolution was seen. Gill et al. [27] recently published a systematic review of the literature on LSG and its effect on DM. Overall, DM resolution was seen in 66.2% and improvement in 26.9%. Lower remission rates in our study could be related to longer duration of disease or more severe disease at baseline in this patient population.

The occurrence of GERD symptoms after LSG is an issue of concern. It has been reported between 2.8 and 13% to as high as 21% [28, 29]. In our study, six patients developed new GERD symptoms for an incidence of 3.24%. None of the patients had a hiatal hernia reported on preoperative gastroscopy. It is known that intragastric pressure increases significantly after sleeve gastrectomy [30]. This in combination with a hypotensive lower esophageal sphincter either preexisting or as a result of LSG could have led to onset of new GERD symptoms [31]. Another proposed mechanism is a relative dilation of the fundal portion of the sleeve with a narrowed distal portion which could lead to stasis and resultant increased acid production [32]. This could happen when excess fundus (a more distensible part of the stomach) is left while fashioning the upper part of the sleeve resection. None of our patients had this finding on upper-gastrointestinal imaging or endoscopy. On the other hand, some have reported improvement or resolution of preexisting symptoms ranging from 40 to 85% [28, 3335]. In this series, preexisting GERD symptoms in 11 patients (45.92%) also resolved or improved. The reason for this resolution is unclear. A faster gastric emptying seen after LSG has been suggested [36], although others have shown no change in gastric transit time [37].

Overall, it appears that LSG results in stable and adequate weight loss. The %EWL is more than that of LAGB and similar to that of LRYGB [38]. Impact on comorbidities shows a resolution or improvement in a majority of the cases. Inadequate weight loss and weight regain is noticed in a small proportion of patients. GERD symptoms can usually be managed with medical therapy or, in refractory patients, with conversion to LRYGB. Although older patients and those with BMI > 50 kg/m2 lost less weight, most of the patients were satisfied with the surgical outcome. Therefore, LSG can be considered a definitive procedure for morbid obesity.

Disclosures

Dr. Ajay Chopra is a surgical consultant for Ethicon Endo-Surgery, Cincinnati, OH. Dr. Edward Chao, Dr. Yana Etkin, Dr. Jayne Lieb, Dr. Harry Delany, and Lynn Merklinger have no conflicts of interest or financial ties to disclose.

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© Springer Science+Business Media, LLC 2011