Laparoscopic Sleeve Gastrectomy as an Isolated Bariatric Procedure: Intermediate-Term Results from a Large Series in Three Austrian Centers
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Gastric sleeve resection was initially planned as the first step of bilio-pancreatic diversion with duodenal switch but it continues to emerge as a restrictive bariatric procedure on its own. We describe intermediate results in a series of 126 laparoscopic sleeve gastrectomies (LSG) compiled from three bariatric centers in eastern Austria.
The stomach was laparoscopically reduced to a “sleeve” along the lesser curvature over a 48-Fr bougie. Special attention was placed on complete resection of the gastric fundus.
After a mean follow-up of 19.1 months, patients had lost between 2.3 and 27 kg/m2 or between 6.7% and 130% of their excessive weight. Sixty four percent of the patients lost >50% of their excess weight within an average of 20 months. Seven percent of the patients had an excess weight loss <25% and were therefore considered as failures. The only major surgical complication was leakage of the staple-line needing revision (three times). There were no operative mortalities.
The final place of LSG in bariatric surgery is still unclear, but our results and those of others show that LSG can be a viable alternative to established procedures.
KeywordsMorbid obesity Bariatric surgery Laparoscopic surgery Gastroplasty Sleeve gastrectomy
The epidemiological increase of obesity and morbid obesity  is a continuing challenge to bariatric surgeons all over the world. Well-established operative techniques for obesity include Roux-en-Y gastric bypass (RYGBP), laparoscopic adjustable gastric banding (LAGB), biliopancreatic diversion with or without duodenal switch (BPD-DS), and others, with an increasing rate of the procedures performed laparoscopically .
Sleeve gastrectomy (SG) was initially devised as the first step of the duodenal switch procedure. Later, laparoscopic sleeve gastrectomy (LSG) was done as an initial procedure in high-risk patients to be followed by laparoscopic RYGBP (LRYGBP) [3, 4] or laparoscopic BPD-DS . In the meantime, some centers have offered LSG as an independent restrictive bariatric method [6, 7, 8]. In this context, it can be seen as a derivative of the earlier Magenstrasse and Mill technique [4, 9].
This retrospective study reports 126 patients that underwent LSG at one of three bariatric surgical centers in Austria. Some patients had had failures of adjustable gastric bandings (although our preferred procedure after failed gastric banding is LRYGBP), but in all cases, LSG was intended as the final bariatric operation and not as a first stage of secondary malabsorptive surgery.
Patients and Methods
Demographic data of 126 patients with laparoscopic gastric sleeve resection
Age at surgery (years)
Preoperative BMI (kg/m2)
Preoperative excessive weight (kg)
Duration of admittance (days)
A different surgical procedure than LSG (usually LRYGBP) was chosen in the case of proven reflux disease, when a significant hiatal hernia was seen in the preoperative barium swallow or at gastroscopy, and when there was a history of “sweet eating.” Informed consent was obtained and the lack of long-term experience with the technique was specifically addressed.
Surgical Procedure, Postoperative Management, and Follow-up
Surgery was started with the patient in a half-sitting position. Five working trocars were used. The first trocar was openly inserted in the middle of the left rectus sheath about halfway between xiphoid and umbilicus. Additional trocars were inserted in the epigastric, left subcostal, right midabdominal, and left midabdominal positions. Intra-abdominal pressure was usually between 12 and 14 mm Hg and kept as low as possible.
Beginning opposite the “crow’s foot,” the stomach was freed from the greater omentum with ultrasonic scissors (Ethicon, Cincinnati, OH, USA) or the Ligasure Atlas™ (Tyco, New Haven, CT, USA) device. At the esophagogastric junction, the left crus of the diaphragm was visualized to ensure complete mobilization of the gastric fundus. After insertion of a 48-Fr gastric tube, the main part of the corpus and, especially, the complete gastric fundus were resected up to the angle of His using a green and several blue 60-mm cartridges of the EndoGIA™ (Tyco) stapler. Thus, the stomach was reduced to a “sleeve” along the lesser curvature. In most cases, the staple-line was oversewn with a running suture (PDS 2-0, Ethicon) to ensure hemostasis along the staple-line after release of the pneumoperitoneum.
A water-soluble contrast swallow was performed on the first postoperative day to exclude leakage. The patients were put on a semisolid/liquid diet for 4 weeks and instructed to take multivitamin substitution daily. Follow-up included regular visits in the outpatient department and blood samples including vitamin B12 and folate levels. A subgroup had barium contrast swallow 1 year after surgery to evaluate for gastric sleeve dilatation .
Data Acquisition and Analysis
Maximum ideal weight was defined as the weight at a BMI of 25 kg/m2 for the individual patient. (We are aware of the limitations of this method for reporting weight loss , but the present study included a very homogeneous middle-European population, where we consider standard definitions of overweight as applicable.) Reported data were expressed as mean ± one standard deviation or as median values and ranges for data that were not normally distributed.
Between 2003 and 2006, 126 patients had LSG in one of the three centers (Table 1). Notably, two patients had surgery after previous liver transplantation. One 15-year-old had the surgery because of Prader–Willi syndrome. Operative and postoperative morbidity included three cases of staple-line insufficiencies needing revisional surgery (one occurred in an open revisional bariatric operation after LABG migration). In two cases, leaks at the staple-line were noted during the operation and oversewn laparoscopically. One patient needed gastrectomy because of a severely stenotic sleeve 10 months after LSG. Therefore, the complication rate was 3.17% for severe complications and 1.58% for minor ones.
Four patients were converted to open surgery; three of them had their sleeve resections because of earlier failed LABG operations. Conversion solely because of technical difficulties was not considered as a complication per se. Three patients had planned open sleeve resections, two because of concomitant incisional hernia repairs and one after LABG migration. Median length of hospital stay was 6.5 days. There were no operative (30-day) mortalities.
With 126 patients, we present one of the largest series of LGS intended as a stand-alone procedure in morbid obesity. A study of similar size  reported 118 patients, of whom 115 had sleeve resection by laparotomy, and in the series of Cottam et al. , 36 of 126 LSG patients went on to LRYGBP after 1 year. Lee et al.  reported 216 patients but with a relatively short follow-up.
Limitations of our study are that it is retrospective and not randomized. Randomization is difficult in bariatric surgery because different techniques are not equivalent. To our knowledge, there is only one relatively small study where LAGB and LSG were compared . Many patients will contact the surgeon with very definite expectations, and we usually accepted the patients’ choice of procedure in a setting of informed consent and in the absence of contraindications for a specific procedure. (For LSG, clinically evident gastroesophageal reflux and sweet-eating were considered as contraindications.) However, LAGB or LRYGBP were usually preferred by patients. Obviously, the prospect of sacrificing the greater part of the stomach forever was the reason to avoid LSG, and the virtual irreversibility of gastric bypass was obviously ignored. On the other hand, LABG was taken for what it is: the least invasive bariatric surgical procedure. Interestingly, there where two physicians in our study who definitely preferred LSG over LAGB or RYGBP. Finally, we chose LSG for two morbidly obese patients after liver transplantations. A relatively long median length of hospital admittance of 6.5 days still reflects the cautionary approach towards a new technique and the traditional experience with partial gastrectomy, albeit laparoscopically.
Baltasar et al.  listed the advantages and disadvantages of LSG comprehensively. In short, LSG is a less extensive procedure than the malabsorptive techniques and results in fewer long-term nutritional deficiencies. For instance, vitamin B12 substitution by intramuscular injection is usually not necessary after LSG. After SG, the alimentary tract remains fully accessible for endoscopy, and the implantation of a foreign body is avoided. Because the procedure is less invasive and can be performed in less time than both the RYGBP and BPD, a two-step approach, especially in superobese patients at high risk, has been advocated . This gives the patient a chance to reduce the operative risk of the second procedure and has opened the path to LSG as an isolated procedure.
Corrections of the gastric tube in the form of resleeve-gastrectomy during second-stage duodenal switch  and reoperative SG in a failure of BPD-DS  have both been performed. The intermediate-term results of LSG are encouraging, and a prospective randomized study  has documented that LSG is superior to LABG in terms of weight reduction and keeping the reduced weight stable after 1 and 3 years. As an initial procedure for high-risk patients, LSG is superior to the gastric balloon .
Whether LSG is a purely restrictive bariatric procedure is still open to discussion . We have shown that LSG, but not LAGB, leads to profound and stable reduction of serum levels of the hunger-inducing hormone ghrelin . The explanation might be that we aim to resect the gastric fundus completely and thereby remove most of the ghrelin-producing cells. Furthermore, we have seen at least one case where the feeling of satiety and the patient’s BMI remained constant despite considerable dilatation of the sleeve 1 year after surgery . The size of the bougie used for calibrating the stomach tube might also influence success, i.e., weight loss, but this correlation appears to be complex and is definitely not linear .
There are no long-term results yet for redo LSG after failed LAGB . As a strategy, the substitution of a restrictive procedure by another mainly restrictive procedure is questionable. In the present series, both conversions to open surgery (three out of four) and primary open procedures (one of three) were overrepresented after LABG failure, and all three centers now tend to convert these patients to laparoscopic RYGBP.
LSG will probably have a place in bariatric surgery of adolescents. For all these reasons, the final place of LSG within the spectrum of bariatric surgical procedures is not yet entirely resolved. Surgery continues to be the only effective cure for morbid obesity, and it is able to reduce cardiovascular risk factors and to improve survival . In the face of the obesity epidemic, bariatric surgeons must continuously expand and improve their strategies, and LSG may become another valuable asset in their armamentarium.