Laparoscopic sleeve gastrectomy as an initial weight-loss procedure for high-risk patients with morbid obesity

  • D. Cottam
  • F. G. Qureshi
  • S. G. Mattar
  • S. Sharma
  • S. Holover
  • G. Bonanomi
  • R. Ramanathan
  • P. Schauer
Original Article

Abstract

Background

The surgical treatment of obesity in the high-risk, high-body-mass-index (BMI) (>60) patient remains a challenge. Major morbidity and mortality in these patients can approach 38% and 6%, respectively. In an effort to achieve more favorable outcomes, we have employed a two-stage approach to such high-risk patients. This study evaluates our initial outcomes with this technique.

Methods

In this study, patients underwent laparoscopic sleeve gastrectomy (LSG) as a first stage during the period January 2002–February 2004. After achieving significant weight loss and reduction in co-morbidities, these patients then proceeded with the second stage, laparoscopic Roux-en-Y gastric bypass (LRYGBP).

Results

During this time, 126 patients underwent LSG (53% female). The mean age was 49.5 ± 0.9 years, and the mean BMI was 65.3 ± 0.8 (range 45–91). Operative risk assessment determined that 42% were American Society of Anesthesiologists physical status score (ASA) III and 52% were ASA IV. The mean number of co-morbid conditions per patient was 9.3 ± 0.3 with a median of 10 (range 3–17). There was one distant mortality and the incidence of major complications was 13%. Mean excess weight after LSG at 1 year was 46%. Thirty-six patients with a mean BMI of 49.1 ± 1.3 (excess weight loss, EWL, 38%) had the second-stage LRYGBP. The mean number of co-morbidities in this group was 6.4 ± 0.1 (reduced from 9). The ASA class of the majority of patients had been downstaged at the time of LRYGB. The mean time interval between the first and second stages was 12.6 ± 0.8 months. The mean and median hospital stays were 3 ± 1.7 and 2.5 (range 2–7) days, respectively. There were no deaths, and the incidence of major complications was 8%.

Conclusion

The staging concept of LSG followed by LRYGBP is a safe and effective surgical approach for high-risk patients seeking bariatric surgery.

Keywords

Laparoscopy Morbid obesity Bariatric surgery Gastric bypass Sleeve gastrectomy High-risk 

References

  1. 1.
    Almogy G, Crookes PF, Anthone GJ (2004) Longitudinal gastrectomy as a treatment for the high-risk super-obese patient. Obes Surg 14: 492–497PubMedCrossRefGoogle Scholar
  2. 2.
    de Virgilio C, Elbassir M, Hidalgo A, Schaber B, French S, Amin S, Stabile BE (1999) Fibrin glue reduces the severity of intra-abdominal adhesions in a rat model. Am J Surg 178: 577–580PubMedCrossRefGoogle Scholar
  3. 3.
    Farkas DT, Vemulapalli P, Haider A, Lopes JM, Gibbs KE, Teixeira JA (2005) Laparoscopic Roux-en-Y gastric bypass is safe and effective in patients with a BMI > or =60. Obes Surg 15: 486–493PubMedGoogle Scholar
  4. 4.
    Holzwarth R, Huber D, Majkrzak A, Tareen B (2002) Outcome of gastric bypass patients. Obes Surg 12: 261–264PubMedCrossRefGoogle Scholar
  5. 5.
    Liu JH, Zingmond D, Etzioni DA, O’Connell JB, Maggard MA, Livingston EH, Liu CD, Ko CY (2003) Characterizing the performance and outcomes of obesity surgery in California. Am Surg 69: 823–828PubMedGoogle Scholar
  6. 6.
    Livingston EH, Ko CY (2002) Assessing the relative contribution of individual risk factors on surgical outcome for gastric bypass surgery: a baseline probability analysis. J Surg Res 105: 48–52PubMedCrossRefGoogle Scholar
  7. 7.
    Milone L, Strong V, Gagner M (2005) Laparoscopic sleeve gastrectomy is superior to endoscopic intragastric balloon as a first stage procedure for super-obese patients (BMI > or =50). Obes Surg 15: 612–617PubMedCrossRefGoogle Scholar
  8. 8.
    Paxton JH, Matthews JB (2005) The cost effectiveness of laparoscopic versus open gastric bypass surgery. Obes Surg 15: 24–34PubMedGoogle Scholar
  9. 9.
    Regan JP, Inabnet WB, Gagner M, Pomp A (2003) Early experience with two-stage laparoscopic Roux-en-Y gastric bypass as an alternative in the super-super obese patient. Obes Surg 13: 861–864PubMedCrossRefGoogle Scholar
  10. 10.
    Ren CJ, Patterson E, Gagner M (2000) Early results of laparoscopic biliopancreatic diversion with duodenal switch: a case series of 40 consecutive patients. Obes Surg 10: 514–523; discussion 524PubMedCrossRefGoogle Scholar
  11. 11.
    Schauer PR, Ikramuddin S, Gourash W, Ramanathan R, Luketich J (2000) Outcomes after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Ann Surg 232: 515–529PubMedCrossRefGoogle Scholar
  12. 12.
    Schauer PR, Ikramuddin S, Hamad G, Eid GM, Mattar S, Cottam D, Ramanathan R, Gourash W (2003) Laparoscopic gastric bypass surgery: current technique. J Laparoendosc Adv Surg Tech A 13: 229–239PubMedCrossRefGoogle Scholar
  13. 13.
    See C, Carter PL, Elliott D, Mullenix P, Eggebroten W, Porter C, Watts D (2002) An institutional experience with laparoscopic gastric bypass complications seen in the first year compared with open gastric bypass complications during the same period. Am J Surg 183: 533–538PubMedCrossRefGoogle Scholar
  14. 14.
    Tichansky DS, Demaria EJ, Fernandez AZ, Kellum JM, Wolfe LG, Meador JG, Sugerman HJ (2005) Postoperative complications are not increased in super-super obese patients who undergo laparoscopic Roux-en-Y gastric bypass. Surg EndoscGoogle Scholar

Copyright information

© Springer Science+Business Media, Inc. 2006

Authors and Affiliations

  • D. Cottam
    • 1
  • F. G. Qureshi
    • 1
  • S. G. Mattar
    • 2
  • S. Sharma
    • 2
  • S. Holover
    • 2
  • G. Bonanomi
    • 2
  • R. Ramanathan
    • 2
  • P. Schauer
    • 3
  1. 1.Department of SurgeryUniversity of Pittsburgh Medical Centre, Veterans HospitalPittsburghUSA
  2. 2.Department of SurgeryUniversity of Pittsburgh Medical CenterPittsburghUSA
  3. 3.Cleveland ClinicClevelandUSA

Personalised recommendations