OBES SURG (2010) 20:1164–1170 DOI 10.1007/s11695-010-0176-1
CLINICAL REPORT
Laparoscopic Sleeve Gastrectomy for Morbid Obesity with Intra-operative Endoscopic Guidance. Immediate Peri-operative and 1-year Results after 25 Patients T. Diamantis & A. Alexandrou & E. Pikoulis & D. Diamantis & J. Griniatsos & E. Felekouras & E. Papalambros
Published online: 14 May 2010 # Springer Science+Business Media, LLC 2010
Abstract Laparoscopic sleeve gastrectomy (LSG) represents a promising alternative option for the surgical treatment of morbid obesity. Its standard technique includes the longitudinal division of the stomach along a bougie of varying diameter. We report in this retrospective study our experience with LSG being performed with the use of intra-operative endoscopy instead of the bougie. Twenty-five consecutive patients (18 women, seven men) with a mean age of 40.2 years and mean body weight of 152.1 kg were submitted to LSG with intra-operative endoscopy in our hospital. The mean preoperative BMI was 53.5 kg/m2. There were no conversions. Mean operative time was 117.5 min. There was no morbidity or mortality. The mean loss of excess body weight (EBW) at 3 months post-op was 19±1.8 kg, at 6 months was 28.6±4.5 kg, and at 1 year post-op was 48.9±3.7 kg (min 11–max 92). In other words the patients had lost 30±5%, 45±7.7%, and 60.8±4.3% of their EBW, respectively. The mean excess body weight loss at the day of the last visit to our outpatient clinic was 52.3±4.3 kg which corresponded to 66.4±4.3% of the total excess weight. LSG with intra-operative endoscopic guidance is a safe and efficient alternative method to treat morbid obesity and is a viable option for surgical units familiar with endoscopic techniques.
T. Diamantis : A. Alexandrou (*) : E. Pikoulis : D. Diamantis : J. Griniatsos : E. Felekouras : E. Papalambros Laiko Athens General Hospital, 1st Department of Surgery of the University of Athens, 17 Agiou Thoma St, 11527 Athens, Greece e-mail:
[email protected]
Keywords Morbid obesity . Laparoscopy . Sleeve gastrectomy . Endoscopy
Introduction The optimal operation for the treatment of morbid obesity and even more particularly of super morbid obesity remains an issue of controversy [1]. Laparoscopic sleeve gastrectomy (LSG) is an evolving new technique that was added in the armamentarium of bariatric surgeons during the last decade [2–4]. The frequency of its use by surgeons treating morbidly obese patients worldwide is ever increasing. For the time being, it is estimated that LSG comprises around 5% of the total yearly performed operations around the world, with a clearly increasing tendency [5]. Despite this evolution, there are still certain issues of debate about LSG that the bariatric surgical community tries to resolve [6], first among them, some technical considerations [7] in order to standardize the technique and optimize its results. Issues of controversy include the optimal caliber of the bougie, which is normally used for the calibration of the stomach, and thus the ideal size of the gastric remnant, which in turn would affect the long-term results of this technique [8], as well as the development of any means for the reduction of peri-operative leak or bleeding rate from the gastric sleeve, which are the main sources of post-operative morbidity and mortality [9]. The use of the endoscope for the calibration of the gastric sleeve instead of the usually used bougie of various sizes can deal with both of these issues. We have been using this technique since 2004 for all our LSGs, even before its first report by Frezza et al. [10], and we report herein our short- and medium-term experience.
OBES SURG (2010) 20:1164–1170
Patients and Methods As of the end of December 2008, 25 morbid obese patients have undergone LSG with the use of intra-operative endoscopy in our Department of Surgery. The operations were performed either as the first part of a planned twostage weight reduction operative strategy for super morbid obesity until 2006 or as a stand-alone option for the definitive treatment of morbid obesity later on. Whenever a second operation was anticipated, it was always meant to be a laparoscopic Roux-en-Y gastric bypass. Preoperative work-up was extensive, including blood tests, abdominal ultrasound, chest X-ray, ECG, echocardiogram, pulmonary functional tests including a sleep apnea study, esophagogastroscopy, and endocrinological, nutritional, and psychiatric evaluation. All patients signed an informed consent document. Concerning our surgical technique, the preparation of the stomach for its division and consequent construction of the gastric tube followed a more or less standard fashion already described by various authors [7]. Interestingly, the procedure was performed on the last five patients in this series with the use of the Da Vinci robotic system, which was effectively installed in our hospital in October 2008, but the overall principles of our surgical technique remained identical. Our modification of the “standard technique” is that, instead of positioning a bougie of a certain size against the lesser gastric curvature and cutting along it, in order to calibrate the gastric remnant, we perform an on-table upper GI endoscopy. The endoscope we used was a FUJINON EG-200 FP type S (FUJI Photo Optical, Japan). The outer diameter of the scope is 9.8 mm, which corresponds to a 29-Fr bougie, and its working length 103 cm. Once the whole stomach was mobilized, from a point 3 to 4 cm proximally from the pylorus to the angle of His, the responsible surgical endoscopist was called in. This could be the resident, the surgical fellow, or even the attending surgeon of the bariatric team himself. In the beginning, it was always the attending surgeon who unscrubbed for the endoscopy and then was scrubbed once again for the stapling of the stomach, leaving the scope to an assistant. After a while, with accumulating experience of the whole team with the procedure and its various stages, the endoscopy could be performed by any member of the bariatric team. Whoever it was planned to be was spared from the operation itself, in order to be available for the endoscopy until the end of the procedure. This saved operation time since the rest of the team could at the same time proceed with the laparoscopic part of the procedure without having to wait for the surgical team to reassemble. After entering the duodenum with the scope, we leave it there as a safely anchored splint that will guide us in the
1165
division of the stomach. The nasogastric tube is retrieved at this point, after the anesthesiologist has aspirated all the air from the stomach. This is quite essential since dilation of the stomach with air can hamper a lot its division with the stapler, and the endoscope cannot aspirate the air since it lies in the first part of the duodenum. Division of the stomach begins with the use of the linear stapler (Echelon 60 endopath stapler, endoscopic linear cutter-straight, Ethicon Endo-surgery Inc). The staple line is always reinforced with buttressing material (GORE SEAMGUARD bioabsorbable staple line reinforcement, W. L. GORE and Associates Inc). Special attention is paid so that there is no residual gastric fundus after the division of the stomach. In order to avoid this situation, we always try to view the left crus and detach the fundus of the stomach from it, so that the angle of His is clearly seen. Additionally, during the division of the stomach, the posterior wall of the stomach is smoothly grasped and retracted laterally towards the left, so as to avoid the inclusion of a posterior gastric bulge in the gastric remnant. Inability to avoid these conditions could be the cause of a long-term treatment failure. Once the whole stomach to be resected has been separated from the gastric sleeve, the endoscope is carefully retracted, with minimal air insufflation, in order to inspect the gastric staple line from its interior aspect for any bleeding points or points suspicious for a gastric staple line disruption. At the same time, a view with the laparoscope can confirm that the remaining stomach is air-tight by trying to detect air bubbles in the water-filled abdomen. Finally, a nasogastric tube is reinserted by the anesthesiologists and the gastric sleeve is filled with diluted povidone solution, in order to check once again for any leaks from the staple line. Any bleeding or suspected leak points are immediately strengthened either with isolated figure-ofeight absorbable stitches or with clips (more frequently), otherwise the gastric staple line is not regularly reinforced. If a simultaneous cholecystectomy was scheduled, it was performed at this point. Drains were not regularly used throughout the whole of this study. According to our protocol, a mandatory upper GI contrast study was always performed on the second postoperative day, and if there were no signs suspicious for a leak, the nasogastric tube was removed. The patients were first allowed to receive liquid diet only on the following day and subsequently were discharged on the fourth postoperative day. Upon discharge, the patients were strictly instructed to receive a liquid diet for 1 week, followed by 4 weeks of a soft, semi-liquid diet. After this period, a 1,200-calorie protein-enriched diet was administered. Protein pump inhibitors were given on the first month. Oral supplements (multivitamins, iron substitutes, calcium, etc.) were given according to laboratory results. Patients
1166
OBES SURG (2010) 20:1164–1170
were reexamined in the outpatient clinic after 1 week, 1 month, 3 months, 6 months, and then in yearly intervals or in case of vomitting or any other alarming sign. Whenever a second operation had been planned for further weight loss (namely a gastric bypass), the time point for this sequel operation was not set. It depended on the rate of EBW loss and the patient’s wish and actual BMI, and it was never less than a year. All statistical analyses were performed with the use of SPSS 17.0. Values were expressed as mean ± SEM.
Results Among the 25 patients in this series, seven were men (28%) and 18 were women. Their mean age was 40.2±2.35 years (min 20–max 59) and their mean body weight at 152± 6.3 kg (98–238). The mean preoperative BMI was 53.5± 1.7 kg/m2 (minimum 40–maximum 72). Details on patients’ demographics and co-morbidities are presented in Table 1. Two patients had been submitted to a laparoscopic adjustable gastric banding procedure 2 and 3 years before being referred to us for LSG. Both had gained weight since, after having enjoyed an initial improvement in their body weight for the first year postoperatively. The lap-band was removed simultaneously with the LSG. Three additional patients were submitted to a simultaneous cholecystectomy. There was no conversion. Mean operative time was 117.5±13.5 min. No patient received any blood transfusion. Four patients had to stay overnight in the ICU. The mean length of hospital stay was at 4.5±0.3 days. No post-operative bleeding or leakage from the staple line occurred in this series of patients. Minor and major post-operative morbidity equaled zero. Accordingly, there was no mortality in this series of 25 patients that underwent LSG with intra-operative endoscopy. No patient in this series was lost to follow-up. The mean follow-up period was 18.3±9.1 months (minimum 12– maximum 46 months). One patient came back with protracted vomit 1 year after LSG and a 100-kg weight Table 1 Patients’ demographics and co-morbidities
COPD chronic obstructive pulmonary disease, CAD coronary artery disease, POVD peripheral vascular occlusive disease a
Mean ± SEM
loss. She underwent upper GI endoscopy and pneumatic dilatation of the remaining gastric tube although no real stenosis was found. This patient subsequently developed gallstone chronic cholecystitis and was submitted to laparoscopic cholecystectomy. The mean loss of EBW at 3 months post-op was 19±1.8 kg and was 28.6±4.5 kg at 6 months. In other words, the patients had lost 30±5% and 45±7.7% of their EBW, respectively. The EBW loss at 1 year post-op was 48.9±3.7 kg (min 11– max 92). The mean percentage of excess body weight loss 1 year post-operatively was 60.8±4.3% (Table 2). The mean excess body weight loss on the day of the last visit to our outpatient clinic was 52.3±4.3 kg (minimum 11, maximum 96), which corresponded to 66.4±4.3% of the total excess weight (minimum 15, maximum 100%). Three out of these 25 patients (12%) were submitted to a second-stage LRYGBP, as it was originally planned. The interval between the original operation and the consequent gastric bypass was 12, 30, and 30 months. These patients had lost 34, 85, and 38 kg, which corresponded to 40%, 60%, and 34% of their total excess weight. The corresponding BMIs at the time of reoperation were 40, 44, and 51 kg/m2.
Discussion High-BMI patients, especially men, comprise a special group of patients, for whom surgical treatment of morbid obesity can be extraordinarily challenging. Thick, heavy abdominal wall limits instrument movements. Massive intra-abdominal fat, increased intra-abdominal pressure, and hepatomegaly hamper visibility and exposure of the gastroesophageal junction. As a consequence, complex bariatric procedures such as laparoscopic RYGBP or biliopancreatic diversion and duodenal switch (BPD–DS) in these patients take longer and carry a significantly higher peri-operative morbidity and mortality. Both surgical complications like anastomotic leaks or medical causes of peri-operative morbidity like cardiopulmonary problems or rhabdomyolysis occur much more frequently in super obese
Variable
Total number of patients, 25
Sex (M:F) Age (years)a Weight (kg)a BMI (kg/m2)a History of diabetes History of hypertension History of sleep apnea Other (COPD, CAD, PVOD, musculoskeletal, etc.)
7:18 (28%) 40.2±2.3 151.8±6.3 53.5±1.7 2 (8%) 6 (24%) 6 (24%) 4 (16%)
OBES SURG (2010) 20:1164–1170
1167
patients. Oliak et al. [11] has reported that the mortality in patients with a BMI greater than 60 kg/m2 who underwent laparoscopic Roux-en-Y gastric by-pass increased to 5% compared to a fair 0.4% for patients with a BMI of less than 60 kg/m2. Gagner’s group in a series of 40 consecutive patients reported a 38% major complication rate associated with one-stage laparoscopic BPD–DS in patients with BMIs exceeding 65, compared with 8% for patients with a BMI between 40 and 60 [12]. In an effort to reduce this increased peri-operative morbidity and mortality for patients with high BMIs who undergo complex bariatric procedures, several centers have advocated a two-stage approach. Regan et al. [13] described first a two-stage operative strategy which consists of a sleeve gastrectomy as the first stage and a subsequent Roux-en-Y gastric bypass or a duodenal switch as the second stage. Schauer et al. also reported their early experience with the two-stage approach in 102 super morbid obese patients. Their treatment plan was a sleeve gastrectomy with an interval Roux-en-Y gastric bypass only when the weight loss after this operation did not “cure” morbid obesity, in other words when patients did not achieve a BMI or =60. Obes Surg. 2002;12:643–7. 12. Ren CJ, Patterson E, Gagner M. Early results of laparoscopic biliopancreatic diversion with duodenal switch: a case series of 40 consecutive patients. Obes Surg. 2000;10:514–23. discussion 524. 13. Regan JP, Inabnet WB, Gagner M. Early experience with twostage laparoscopic Roux-en-Y gastric bypass as an alternative in the super-super obese patient. Obes Surg. 2003;13:861–4. 14. Schauer PR, Ikramuddin S, Hamad G, et al. The learning curve for laparoscopic Roux-en-Y gastric bypass is 100 cases. Surg Endosc. 2003;17:212–5. 15. Langer FB, Bohdjalian A, Felberbauer FX, et al. Does gastric dilatation limit the success of sleeve gastrectomy as a sole operation for morbid obesity? Obes Surg. 2006;16:166–71. 16. Mongol P, Chosidow D, Marmuse JP. Laparoscopic sleeve gastrectomy as an initial bariatric operation for high-risk patients: initial results in 10 patients. Obes Surg. 2005;15:1030–3. 17. Milone L, Strong V, Gagner M. Laparoscopic sleeve gastrectomy is superior to endoscopic intragastrric balloon as a first stage procedure for super-obese patients (BMI≥ 50). Obes Surg. 2005;15:612–7. 18. Baltasar A, Serra C, Perez N, et al. Laparoscopic sleeve gastrectomy: a multi-purpose bariatric operation. Obes Surg. 2005;15:1124–8. 19. Cottam D, Qureshi FG, Mattar G, et al. Laparoscopic sleeve gastrectomy as an initial weight-loss procedure for high-risk patients with morbid obesity. Surg Endosc. 2006;20:859–63. 20. Roa PA, Kaidar-Person O, Pinto D, et al. Laparoscopic sleeve gastrectomy as treatment for morbid obesity: technique and shortterm outcome. Obes Surg. 2006;16:1323–6. 21. Givon-Madhala O, Spector R, Wasserberg N, et al. Technical aspects of laparoscopic sleeve gastrectomy in 25 morbidly obese patients. Obes Surg. 2007;17(6):722–7. 22. Lowham ES, Filipi CJ, Hinder RA, et al. Mechanisms and avoidance of esophageal perforation by anesthesia personnel during laparoscopic foregut surgery. Surg Endosc. 1996;10:979– 82. 23. Trus TL, Bax T, Richardson WS, et al. Complications of laparoscopic paraesophageal hernia repair. J Gastrointest Surg. 1997;1:221–8. 24. Moon HS, Kim WW, Oh HJ. Results of laparoscopic sleeve gastrectomy (LSG) at 1 year in morbidly obese Korean patients. Obes Surg. 2005;15:1469–75. 25. Sillecchia G, Boru C, Pecchia A, et al. Effectiveness of laparoscopic sleeve gastrectomy (first stage of biliopancreatic diversion with duodenal switch) on co-morbidities in super-obese high-risk patients. Obes Surg. 2006;16:1138–44. 26. Melissas J, Koukouraki S, Askoxylakis J, et al. Sleeve gastrectomy: a restrictive procedure? Obes Surg. 2007;17:57–62. 27. Fuks D, Verhaeghe P, Brehant O, et al. Results of laparoscopic sleeve gastrectomy: a prospective study in 135 patients with morbid obesity. Surgery. 2009;145:106–13.
