OBES SURG (2009) 19:684–687 DOI 10.1007/s11695-008-9677-6
RESEARCH ARTICLE
Complications After Sleeve Gastrectomy for Morbid Obesity Eldo E. Frezza & Sheila Reddy & Laura L. Gee & Mitchell S. Wachtel
Received: 25 June 2008 / Accepted: 28 August 2008 / Published online: 16 October 2008 # Springer Science + Business Media, LLC 2008
Abstract Background Laparoscopic sleeve gastrectomy (LSG) is an increasingly used bariatric surgical procedure. Methods We report our complications after LSG and compared to 17 other published LSG series. The individual types of complications for the published series were evaluated, with sample size calculations being performed to determine the number of patients required for a study that would detect halving the odds of the most common complications. Results Of 53 patients who underwent LSG, 42 were women. Mean age was 51 years with a mean initial body mass index of 53.5 kg/m2 and mean of eight comorbidities. Mean excess weight loss was 52.2% at 12 months and 59.2% at 18 months. No patients died. Five patients (9.4%) developed complications which included two staple line leaks that required reoperations, one preceded by a salmonella infection associated with vomiting, the other by postoperative pneumonia associated with coughing. Of
the three staple line hemorrhages, one required hospitalization. The median complication rate for the 17 articles was 4.5%. With the number of patients for each series taken into account, the current series had a complication rate of 1.24 (95% CI 0.45–2.87) times that of the 17 published series. Published LSG complications were diverse, with the most common being reoperation, occurring after 3.6% of procedures. A study designed to detect halving the odds of reoperation would require more than 3,000 procedures. Conclusion LSG is a safe procedure with low morbidity. Because leaks and reoperation in this series were preceded by large increments in intraabdominal pressure, attention to staple line reinforcements that increase burst pressure may be warranted.
Paper presented at the North Texas ACS meeting in Dallas on February 21, 2008. Received award as best paper in GI surgery.
Introduction
E. E. Frezza (*) Department of Surgery, The University of Alabama at Birmingham, 700 South 19th Street, VAMC 112, Birmingham, AL 35233, USA e-mail:
[email protected]
Laparoscopic sleeve gastrectomy (LSG) is an increasingly used bariatric surgical procedure [1] with sporadically reported complication rates [2–4]. LSG restricts the stomach’s size to induce satiety [1] and resects fundal ghrelin-producing cells to decrease appetite [2]. This paper analyzes complications of 53 consecutive LSG procedures and evaluates the nature of the complications after sleeve gastrectomy in published series.
S. Reddy : L. L. Gee Division of General Surgery, Department of Surgery, Texas Tech University Health Sciences Center, 3601 4th Street, MS 8312, Lubbock, TX 79430, USA M. S. Wachtel Department of Pathology, Texas Tech University Health Sciences Center, Lubbock, TX, USA
Keywords Sleeve gastrectomy . Complications . Buttress material . Leak . Oozing . Morbid obesity
Methods and Procedures This retrospective study of patients who underwent LSG between January 2005 and January 2008 was approved by
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Table 1 Summary of our patients
Table 3 Complication and mortality rates for 810 published sleeve gastrectomy procedures
Parameters
Values
Male Female Mean age BMI Operating room time % EWL
11 42 51 years 53.5 kg/m2 70 min 52.2 at 12 months; 59.2 at 18 months
Study
our Institutional Review Board. Staple line reinforcement was provided by either SeamGuard (W.L. Gore & Associates, Inc, Newark, DE, USA) or Peri-Strips (Synovis, St. Paul, MN, USA). Gastric stenting was provided by either a 29-French endoscope (Olympus Center Valley, PA, USA) or a 38-French bougie. Resection was accomplished with green and/or blue staples (Covidien, Norwalk, CT, USA) [5]. LSG was performed by standard methods, as previously described [1–4]. A PubMed search was performed using the term sleeve gastrectomy to obtain published series of LSG procedures; studies were included if the numbers of complications and deaths were provided. Poisson regression, using R, calculated a point estimate and 95% confidence interval of the ratio of the complication rate in the present series to the complication rates of the 17 published articles. The null hypothesis was rejected when P< 0.05. Power analysis was performed by an online calculator (http://department.obg.cuhk.edu.hk/researchsupport/ Sample_size_Likert.asp).
Results Of 53 patients, 42 were women. The mean age was 51 years. The mean initial body mass index was 53.5 kg/m2. Patients had a mean eight comorbidities, which included hypercholesterolemia, diabetes, hypertriglyceridemia, sleep apnea, joint pain, dysuria, dysmenorrhea, depression, gastroesophageal reflux disease, arrhythmias, and deep venous thrombosis. Mean operating room time was 70 min. Median follow-up was 18 months. Mean excess weight loss was 52.2% at 12 months and at 59.2% at 18 months. No patients died (Table 1). Three patients developed postoperative staple line hemorrhage or bleeding (5.6%). One, who had been on Table 2 Complications after LSG Parameters
Values
Bleeding Oozing Leaks Return to operating room
1.8 3.7% 3.7% 5.6%
(n=1) (n=2) (n=2) (n=3)
Himpens [6] Hammoui [9] Roa [10] Mognol [11] Silecchia [12] Lee [13] Cottam [14] Catheline [15] Langer [8] Han [16] Baltasar [17] Langer [7] Milone [18] Regan [19] Lalor [4]
Patients
Complication rate (%)
Mortality rate (%)
40 118 30 10 41 216 126 4 23 60 31 10 20 7 164
5 15 13 0 0 6 14 25 4 1 3 0 5 29 3
0 1 0 0 0 0 1 0 0 1 3 0 0 0 0
Coumadin and placed postoperatively on Lovenox, required readmission to the hospital and blood transfusion; hemorrhage resolved after the Lovenox dose was reduced from 2 to 1 kg. One patient developed staple line oozing that resolved spontaneously. One patient was returned to the operating room (OR) for exploration. Two patients developed staple line leaks (3.7%) that required operative correction (Table 2): one was preceded by a salmonella infection that induced vomiting; the other followed post-operative pneumonia with coughing. Both of the patients returned to the OR for a drainage procedure and for reconstruction after 3 months.
Table 4 Frequency distribution of complication by type after sleeve gastrectomy procedures of series displayed in Table 3 Complication
N
Percentage
Reoperations Leak Prolonged ventilator requirements Strictures Renal insufficiency Postoperative hemorrhage Atelectasis Pulmonary embolus Delayed gastric emptying Gastric dilation Prolonged vomiting Subphrenic abscess Trocar site infection Urinary tract infection Splenic injury Trocar site hernia Death
29 7 5 6 4 3 2 2 2 1 1 2 1 1 1 1 4
3.6 0.8 0.6 0.7 0.5 0.4 0.2 0.2 0.2 0.1 0.1 0.2 0.1 0.1 0.1 0.1 0.5
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A PubMed search uncovered 17 series that reported mortality and morbidity after LSG. The reports evaluated a total of 810 procedures. Table 3 displays mortality and complication rates by publication [6–19]. The median complication rate for the 17 studies was 4.5%. Poisson regression calculated that with the number of patients for each study taken into account, the complication rate for the current series was 1.24 (95% CI 0.45–2.78) times that of the published series; the result was not statistically significant (P=0.59). Table 4 displays the number and percents by type of complication for the 810 published procedures. Complications were diverse with no individual type being common, implying a large sample size to detect even very large changes in complication rates. The most common complication, reoperation, occurred in 3.6% of cases. Assume a procedural change halved the odds of reoperation; detecting this large drop with 80% confidence and α=0.05, two tailed, would require 1,649 patients per analysis group or a total of 3,298 patients.
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LSG. Even in the case of complications, the risks are so low that detecting a halving of the risk of the most common, reoperation, would require a study of more than 3,000 patients. The analysis is thus a testimony to the safety of LSG. The first consensus on LSG [23] was held in New York last October and was attended by many physicians worldwide. Our paper supports the conclusion of that symposium which showed that LSG is a feasible, with a low complication rate, and growing operation in the bariatric field.
Conclusion LSG is a safe procedure with low morbidity. Because leaks and reoperation in this series were preceded by large increments in intragastric pressure, attention to staple line reinforcements that increase burst pressure may be warranted.
Disclosure The authors have no conflict of interest.
Discussion It is clear from our data that 53% at 12 months and 59.2% at 18 months represents good weight loss after LSG, which is very promising for the future of this operation and similar to what is reported in the literature [6–8, 20–21]. Few published papers have addressed the complications after LSG. This is still an important subject that needs to be evaluated before considering LSG as a standard bariatric procedure. Five of 53 (9.4%) LSG procedures yielded complications, not significantly different from the overall rates reported in the literature. The patients in our series who required reoperation for leaks had complications occur after marked increases in intragastric pressure. The other three patients experienced staple line hemorrhage, only one of whom required hospitalization. Reoperation and anastomotic leak were the two most common complications. Both of our patients with an anastomotic leak required reoperation. Migration of bovine pericardium strips (Peri-strips) has been related to leaks along the staple line [22], but our patients likely suffered leaks due to intraabdominal pressure caused by emesis and coughing. Of the 810 procedures described in Tables 3 and 4, only four resulted in death. One was secondary to a traumatic trocar insertion. A second occurred in the perioperative period. A third resulted from a leak that occurred within 2 weeks after surgery. A fourth arose from a pulmonary embolus 3 months after surgery. The rare deaths that were seen arose from diverse causes, precluding any real hypotheses about means of reducing the risk of death after
References 1. Frezza E. Laparoscopic vertical sleeve gastrectomy for morbid obesity. The future procedure of choice? Surg Today. 2007;37:275–81. 2. Gumbs AA, Gagner M, Dakin G, et al. Sleeve gastrectomy for morbid obesity. Obes Surg. 2007;17:962–9. 3. Shikora S. The use of staple-line reinforcement during laparoscopic gastric bypass. Obes Surg. 2004;14:1313–20. 4. Lalor PF, Tucker ON, Szomstein S, et al. Complications after laparoscopic sleeve gastrectomy. Surg Obes Relat Dis. 2008;4: 33–8. 5. Carmichael AR, Sue-Ling HM, Johnston D. Quality of life after the Magenstrasse and Mill procedure for morbid obesity. Obes Surg. 2001;11:708–15. 6. Himpens J, Dapri G, Cadiere GB. A prospective randomized study between laparoscopic gastric banding and laparoscopic isolated sleeve gastrectomy: results after 1 and 3 years. Obes Surg. 2006;16:1450–6. 7. Langer FB, Reza Hoda MA, Bohdjalian A. Sleeve gastrectomy and gastric banding: effects on plasma ghrelin levels. Obes Surg. 2005;15:1024–9. 8. Langer FB, Bohdjalian A, Felberbauer FX. Does gastric dilatation limit the success of sleeve gastrectomy as a sole operation for morbid obesity? Obes Surg. 2006;16:166–71. 9. Hammoui N, Anthone GJ, Kaufman HS, et al. Sleeve gastrectomy in the high-risk patient. Obes Surg. 2006;16:1445–9. 10. Roa PE, 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. 11. Mognol P, Chosidow D, Marmuse JP. Laparoscopic sleeve gastrectomy (LSG): review of a new bariatric procedure and initial results. Surg Technol Int. 2006;15:47–52. 12. Silecchia G, Boru C, Pecchia A, et al. Effectiveness of laparoscopic sleeve gastrectomy (first stage of biliopancreatic
OBES SURG (2009) 19:684–687
13.
14.
15.
16.
17. 18.
diversion with duodenal switch) on co-morbidities in super-obese high-risk patients. Obes Surg. 2006;16:1138–44. Lee CM, Cirangle PT, Jossart GH. Vertical gastrectomy for morbid obesity in 216 patients: report of two-year results. Surg Endosc. 2007;21:1810–6. Cottam D, Qureshi FG, Mattar SG, et al. Laparoscopic sleeve gastrectomy as an initial weight-loss procedure for high-risk patients with morbid obesity. Surg Endosc. 2006;20:859–63. Catheline JM, Cohen R, Khochtali I, et al. [Treatment of super super morbid obesity by sleeve gastrectomy]. Presse Med. 2006;35:383–7. Han SM, Kim WW, Oh JH. Results of laparoscopic sleeve gastrectomy (LSG) at 1 year in morbidly obese Korean patients. Obes Surg. 2005;15:1469–75. Baltasar A, Serra C, Perez N, et al. Laparoscopic sleeve gastrectomy: a multi-purpose bariatric operation. Obes Surg. 2005;15:1124–8. Milone L, Strong V, Gagner M. Laparoscopic vertical sleeve gastrectomy is superior to endoscopic intragastric balloon as a first
687
19.
20.
21.
22.
23.
stage procedure for super-obese patients (BMI>50). Obes Surg. 2005;15:612–7. Regan JP, Inabnet WB, Gagner M, et al. Early experience with two-stage laparoscopic Roux-en-Y gastric bypass as an alternative in the super-super obese patient. Obes Surg 2003;13:861–4. Akkary E, Duffy A, Bell R. Deciphering the sleeve: technique, indications, efficacy, and safety of sleeve gastrectomy. Obes Surg. 2008;18:1323–29. Vidal J, Ibarzabal A, Romero F, et al. Type 2 diabetes mellitus and the metabolic syndrome following sleeve gastrectomy in severely obese subjects. Obes Surg. 2008;18:1077–82. Consten E, Gagner M, Pomp A, et al. Decreased bleeding after laparoscopic sleeve gastrectomy with or without duodenal switch for morbid obesity using a stapled buttressed absorbable polymer membrane. Obes Surg. 2004;14:1360–6. Deitel M, Crosby RD, Gagner M. The first international consensus summit for sleeve gastrectomy (SG), New York City, October 25–27, 2007. Obes Surg. 2008;18:487–96.
