Our 1-Year Experience in Laparoscopic Sleeve Gastrectomy
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- Ramalingam, G. & Anton, C.K.S. OBES SURG (2011) 21: 1828. doi:10.1007/s11695-011-0484-0
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Sleeve gastrectomy was conceived in 1988 both as a first step to the duodenal switch procedure and as an extension of anti-reflux surgery where patients lost significant weight. It is now a stand-alone laparoscopic bariatric procedure worldwide with two international consensus summits identifying it as a safe and feasible restrictive and appetite-suppressing procedure. In our centre, it is a key component in the surgical armamentarium and used as a first-line and revisional procedure for morbid obesity. The procedure is performed using standard five port technique. One year results are reviewed for its feasibility in our Asian patients. Twenty of 48 laparoscopic sleeve gastrectomies have a 1-year follow-up with four of them a revisional procedure for bands with complications. There were 11 males and 9 females (average age 43.6) and a representation of all four major ethnic groups. Average weight and BMI improved from 116.3 to 90.2 kg and 42.5 to 33.1 kg m-2 after 1 year, respectively. Average weight loss was 26.1 kg and excess weight loss (in percent) was 49.6%. There was an improvement in diabetes mellitus, hypertension, obstructive sleep apnoea and asthma and three complications including two leaks and a gastro-oesophageal spasm/stricture. Laparoscopic sleeve gastrectomy is safe and feasible as first-line surgery for morbid obesity and revisional procedures for band-related complications in the short term. Further studies are required to elucidate the exact mechanisms of weight loss in the sleeve gastrectomy to answer the appropriateness of the variations in the technique and long-term weight loss and morbidity.
The first sleeve gastrectomy was reported to be performed as an open procedure by Dr. Doug Hess in March 1988 [1, 2] as part of a duodenal switch surgery for obesity. In a similar development, Dr. Lawrence Tretbar  also described a procedure that was an extension of the fundoplication for antireflux surgery that created a tubular stomach which he noted to have achieved weight loss. Dr. Gagner performed the laparoscopic duodenal switch successfully in humans after a trial in the porcine model in 1999. However, he noticed that the complication rate was high in patients with a higher body mass index [4, 5]. In a bid to improve the safety profile of an intestinal bypass for these patients, he performed it in two stages, starting with a laparoscopic sleeve gastrectomy  and later, a bypass. It was noticed that the sleeve gastrectomy alone caused good weight loss before the second part was performed. Earlier, it was noted that an extended vertical gastroplasty, the Magenstrasse and Mill operation , where the lesser curve of the stomach was made a tubular structure with a 32 F diameter till the antrum, also showed good weight loss.
Laparoscopic sleeve gastrectomy as a stand-alone procedure has since grown throughout the world and has been verified by the First  and Second  International Consensus Summit for Sleeve Gastrectomy in 2007 and 2009, respectively, as a safe and feasible bariatric procedure. It is a restrictive procedure, but with the removal of the fundus of the stomach, it reduces the volume of the glands that produce ghrelin and thus also functions as an appetite suppressing  one as well. That sleeve gastrectomy has become the most popular bariatric surgery procedure in Asia has been well reported [11, 12]
Our own experience with bariatric surgery began with exclusively laparoscopic adjustable gastric banding (LAGB) in 2001 . Laparoscopic sleeve gastrectomy was introduced in 2007. Limited to a few patients initially, it has grown to be the most popular bariatric procedure of choice for our patients , both as a primary and a revision procedure . It is thus important to review our early result of laparoscopic sleeve gastrectomy as a primary procedure to assess its feasibility in our centre and our population of patients.
In our weight management centre, patients were accepted for surgery if they satisfied the guidelines of the Society of American Gastroenterological Surgeons  and the Ministry of Health of Singapore Clinical Practice Guidelines for Obesity . Our inclusion criteria were previous failed attempts at losing weight, body mass index (BMI) criteria of >32.5 with comorbidity and >37.5 without comorbidity and age between 18 and 65. Patients with severe organ dysfunction, major psychiatric dysfunction and substance abuse or eating disorders were excluded. Patients are made to undertake a structured weight management program for 4 months in the Health for Life Centre. This would include appointments with a dietician, physiotherapist and endocrinologist. During the surgical consult, the various types of surgical procedures would be explained to the patient, including the advantages or otherwise of each. Complications, the change in lifestyle and the need for life-long follow-up were emphasized. Details were supplemented with audiovisual aids.
Standard preoperative and metabolic blood investigations are carried out. Gastroscopy and ultrasound of the gallbladder were performed. An overnight polysomnography was arranged to quantify obstructive sleep apnoea (OSA) and where necessary, continuous positive airway pressure therapy is initiated at least 2 weeks prior to surgery and 2 weeks post-operatively. Selected patients were given a low calorie diet for at least 2 weeks prior to surgery. An anaesthetic review is arranged prior to surgery.
The patient is admitted on the morning of the surgery and subcutaneous heparin and graduated compression stockings are used for deep vein thrombosis prophylaxis. Intraoperatively, the patient is placed in a reverse Trendelenberg position. The surgeon stands in between the legs and the assistant stands to the patient’s right.
We use the standard five port positioning and two of the ports are 12 mm while the rest are 5 mm. After the liver is retracted with a Nathanson liver retractor, a 38-F calibration tube is then inserted along the lesser curve of the stomach and the lesser sac is entered 6 cm proximal to the pylorus, which is the point where the sleeve gastrectomy is performed. As the greater curve is mobilized proximally, a linear stapler used to perform the sleeve gastrectomy follows in parallel. The last linear staple comes very close to, but not touching, the gastro-oesophageal junction. Hemostasis of the staple line and the dissected fat lateral to the greater curve is meticulous. The staple line is oversewn. A gastroscopy is then performed and a leak test is done with insufflation of air into the stomach via gastroscopy and observation via laparoscopy after submerging the staple line in water. A drain was left for a couple of days.
A contrast swallow is performed the next day and if there was no leak, patients were started on a liquid diet after consultation with the dietician. They would usually be discharged the same evening or the next day with a follow-up appointment in 2 weeks. At the first outpatient review, the patients will be again seen by the surgeon and the dietician and they will be encouraged to start a balanced diet. Subsequent appointments will be 1, 3, 6 and 12 months. At all appointments, the eating habits will be closely monitored as will the anthropometric data and patients with a medical history of diabetes mellitus, hypertension and hyperlipidemia will be closely followed up by an endocrinologist.
Number of sleeve gastrectomies performed per year
Age range (average) (years)
The average weight of the patients was 116.3 kg with the weight ranging between 79.3 to 196.6 kg. The average BMI was 42.5 kg m−2  with the range being between 31.4 and 60. The patient with a BMI of 31.4 initially was almost at BMI 35 when she was listed for surgery but in the intervening 6 weeks she lost a substantial amount of weight due to the preoperative advice given to her. She was the only patient operated in this series that has a BMI below 35. The average excess weight of the patients (measured from a BMI of 23) was 53.6 kg ranging between 21.2 and 121.2 kg.
Weight average (range)(kg)
BMI average (range) (kg m−2)
Excess body weight average (range) (kg)
Results at 1 year
Weight average (range) (kg)
BMI average (range) (kg m−2)
Weight loss average (range) (kg)
Excess body weight loss average (range) (%)
Improvement in comorbidity
Obstructive sleep apnoea
Staple line leak
Spastic lower oesophageal sphincter
Laparoscopic sleeve gastrectomy (LSG) burst onto the scene in the last 12 years or so. The increasing volume of literature on this procedure gives a very clear indication of its popularity even despite the loss of favour of its close “cousin” the Magenstrasse and Mill operation as suggested by Huttl et al. . There are newer modifications of the LSG, namely the laparoscopic greater curve plication that has a similar restrictive mechanism without the potential leaks from a “staple line” in the LSG .
Our 1-year results are comparable to other Asian series. A Korean publication of 60 patients by Sang et al.  stated that the excess weight loss at 1 year was 83.3 ± 28.3% with a decrease of BMI being 9.2 ± 3.7 kg m−2 and good resolution of their comorbidities. Similar results were noted in an Indian series by Chowbey et al. . Our results were reflected in a similar light in other series in Europe [22, 23] and North America 
In our own series, we have shown that this procedure is safe and feasible in the short term, not only as a primary procedure, but as a revision procedure for the complications of LAGB . This is especially so if the restrictive LAGB was initially working well and the patient developed a slippage or other complication of the band that did not respond to simply removing all the fluid (which would usually suffice in the majority of cases). Failed LAGB, where patients fail to lose weight or regain weight, will probably not benefit from another restrictive operation. A Roux-en-Y gastric bypass is more likely to work in this circumstance and is our revision procedure of choice in this circumstance at present. The four patients who had a laparoscopic sleeve gastrectomy after a band complication have all lost more than 40% of their excess body weight after 1 year.
The restrictive nature of the LSG has been elegantly demonstrated by Yehoshua et al. . This is despite the fact that a LSG also has appetite-suppressing qualities . Dr. Gagner [4, 6] has originally shown that the LSG is safe for the very high BMI. And corresponding with our study and that done by Gluck et al. , the lower BMI patients also benefit as well. It has also been seen that this procedure is compatible with high-risk patients . Its versatility and safety profile are the main reasons why our patients have made this operation the procedure of choice in our unit.
The staple line leak is the most dreaded complication. Most of the leaks are reported to be near the gastro-oesophageal junction. A leak rate of 1% to 3% for primary procedure  and more than 10% in revision procedures has been reported [31, 32]. Our first leak was in a revision procedure where the band removal and sleeve gastrectomy were carried out at the same setting. We have since learned our lesson. We now separate the two procedures  by 6 to 12 weeks. The other leak occurred within the first five procedures we performed, probably as part of the learning curve.
Management of leaks can be frustrating. Intervention ranging from simple drainage, nutritional support and waiting  to the use of glue  and stents  has been reported. We have also shown that conservative treatment with drains and nutritional support is a viable option, and if that failed, we moved on to insertion of stents. The final complication was either a failure to identify a pathology that was present preoperatively (lower oesophageal sphincter spasm ) or a narrowed gastro-oesophageal junction post-surgery  that fortunately was successfully treated with an endoscopic dilatation.
There are variations in the detail of the sleeve gastrectomy procedure itself. One point of contention is the reinforcement of the staple line. These range  from suturing the whole length of the suture line to reinforcing the gap between the staples to the use of absorbable polymer membranes and glue. While there were reports of lower suture line haemorrhage, there was no indication that leak rate improves with reinforcement. No reinforcement is also an option for some . Our experience has shown that this is a safe practice even though there is no definitive literature that supports a substantial benefit of reinforcement.
Most surgeons use a calibration tube of anywhere between 32 and 60 F (used by Milone et al. ) to measure the size of the retained stomach. There is also the issue of where one put the stapler, snug with the calibration tube or a little way away. Regardless of this, it has been reported that there is similar weight loss, at least early post-surgery, with calibration size between 32 and 44 F . It is only when size went to 60 F before any differences appears. Most surgeons report the use of 30–40 F size  of calibration tube.
A neat study by Dapri et al.  that compared our method of performing the sleeve, where the mobilization of the stomach is done in parallel with the stapling of the stomach, with doing the full mobilization of the stomach prior to stapling has shown to have no difference in terms of outcome after surgery. There is variability in the distance from the pylorus where the sleeve gastrectomy is begun. Our technique is to start the stapling of the sleeve 6 cm proximal to the pylorus , but we are aware of those who start much closer, less than 2 cm  away from it. However, there are no differences in weight loss or gastric emptying with the between these distances.
In conclusion, from our initial series, we find that the laparoscopic sleeve gastrectomy is safe and feasible not only as the first-line surgery for morbid obesity but also viable as a revision procedure for band-related complications, in the short term. There are many variations in the technique that may affect the weight loss and complication rates of the procedure. Further conclusive studies are still anticipated to elucidate the exact mechanisms involved in weight loss in the sleeve gastrectomy to answer the appropriateness of the variations in the technique  and their long-term results as well.
Conflicts of interest
All the authors in the paper have no conflicts of interest.