OBES SURG (2016) 26:2654–2660 DOI 10.1007/s11695-016-2165-5
ORIGINAL CONTRIBUTIONS
Early Weight Recidivism Following Laparoscopic Sleeve Gastrectomy: A Prospective Observational Study Mohamed H. A. Fahmy 1 & Mohamed D. Sarhan 1 & Ayman M. A. Osman 1 & Ahmad Badran 1 & Amr Ayad 1 & Dalia K. Serour 2 & Hany A. Balamoun 1 & Mohamed E. Salim 1
Published online: 7 April 2016 # Springer Science+Business Media New York 2016
Abstract Background Although weight loss following laparoscopic sleeve gastrectomy (LSG) can be substantial, weight recidivism is still a major concern. The aim of our work is to study early weight recidivism following LSG and to evaluate the role of gastric computed tomography volumetry (GCTV) in the assessment of patients experiencing early weight regain. Methods One-hundred and one morbidly obese patients undergoing LSG were prospectively studied. Patients were followed up for 2 years. Those who presented with weight recidivism were counseled for dietary habits and assessed
* Ayman M. A. Osman
[email protected];
[email protected] Mohamed H. A. Fahmy
[email protected] Mohamed D. Sarhan
[email protected] Ahmad Badran
[email protected] Amr Ayad
[email protected]
for the amount of weight regain. Patients who regained weight were scheduled for GCTV. Results Twelve patients were excluded from the study. Weight recidivism was reported in 9/89 patients (10.1 %) [weight loss failure (n = 1), weight regain (n = 8)] and was almost always first recognized 1½–2 years after LSG. The amount of weight regain showed negative correlations with preoperative body weight and body mass index (r = −0.643, P = 0.086 and r = −0.690, P = 0.058; respectively) and positive correlations with the distance between the pylorus and the beginning of the staple line (r = 0.869, P = 0.005), as well as with the residual gastric volume (RGV) on GCTV 2 years after LSG (r = 0.786, P = 0.021). Conclusions In the small group of patients who regained weight, a longer distance between the pylorus and the beginning of the staple line, as well as a higher RGV on GCTV 2 years after LSG, were both associated with increased weight regain. Gastric computed tomography volumetry with RGV measurement holds promise as a useful research tool after LSG. Keywords Laparoscopic sleeve gastrectomy . Weight recidivism . Gastric computed tomography volumetry . Residual gastric volume
Dalia K. Serour
[email protected] Hany A. Balamoun
[email protected] Mohamed E. Salim
[email protected] 1
Department of General Surgery, Faculty of Medicine, Cairo University, Cairo, Egypt
2
Department of Radiodiagnosis, Faculty of Medicine, Cairo University, Cairo, Egypt
Introduction With the growing severity of the obesity epidemic over the past few decades [1], the number of weight loss procedures performed worldwide has increased significantly [2]. Laparoscopic sleeve gastrectomy (LSG) is a relatively new and effective bariatric surgical procedure. It has recently gained popularity as a stand-alone procedure because of its relative simplicity, non-disruption of the gastrointestinal tract,
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lack of foreign body implantation and gastrointestinal anastomoses, nearly regular intestinal absorption, low incidence of dumping syndrome, and 0 % risk of developing an internal hernia [3–8]. LSG has been shown to be effective in reducing excess weight by up to 70 and 60 % within 3 and 5 years, respectively [9, 10]. Weight recidivism is an important issue and a concern for many patients after bariatric surgery [11]. A devastating consequence of such problem is the possible recurrence of obesity-related co-morbidities [e.g., type 2 diabetes mellitus (T2DM)] [12]. A recent systematic review has identified five principal etiologies for weight recidivism representing nutritional indiscretion, endocrine/metabolic alterations, mental health issues, physical inactivity, as well as anatomic surgical failure [13]. Owing to the relative infancy of the LSG procedure, data on long-term weight recidivism following LSG is still deficient [7]. The aim of this work is to study early weight recidivism following LSG in terms of incidence, timing, amount of weight regain, and possible contributing factors as well as to evaluate the role of gastric computed tomography volumetry (GCTV) in the assessment of patients experiencing early weight regain.
Materials and Methods One-hundred and one morbidly obese patients undergoing LSG in Kasr Al-Aini Hospital, Cairo University, between January 2011 and December 2012 were prospectively studied. Patients were selected on the basis of strict inclusion and exclusion criteria (Table 1). Body weight (BW) and BMI were recorded preoperatively in all patients. The surgical technique was standardized in all cases. Following insufflation, four 12-mm trocars were introduced (right and left upper quadrant trocars, an epigastric trocar, a supra-umbilical trocar just to the left of the midline). A fifth 5mm trocar was inserted at the left anterior axillary line. After placing the patient in anti-Trendelenburg position, the greater omentum was dissected from the greater curvature of the stomach, starting from a point 3–4 cm proximal to the pylorus Table 1 Inclusion and exclusion criteria used for patient selection in our study
all the way up till the angle of His using the ultracision Harmonic scalpel. A 36-Fr bougie was then advanced orally by the anesthetist and positioned in the pylorus. Gastric transection was started 3–6 cm proximal to the pylorus using an Endo-GIA linear stapler (Ethicon Endo-Surgery, Cincinnati, OH). The stapler was first placed across the antrum and fired. The distance between the pylorus and the beginning of the staple line was recorded in every case. Sequential stapler firings, in the direction of the gastroesophageal junction, were used to transect the stomach 1–2 cm from its lesser curvature up to the angle of His. A 60-mm green or gold cartridge was used for the first stapler firing, while blue cartridges were used for subsequent firings. Finally, the entire staple line was carefully inspected and its integrity tested by a methylene blue test. A 20-Fr nelaton drain was placed, and trocar sites were closed. Patients were placed on a liquid-only diet for 1 month, then a semi-solid diet for 2 weeks, followed by mashed food for another 2 weeks. After that, a regular healthy diet was started. Patients were instructed to come for follow-up at 6-month intervals for at least 2 years. Body weight and BMI readings were taken each visit. Early weight regain was defined as a regain of ≥5 % of the BW that had been initially lost, occurring 12–24 months after LSG. Patients who failed to lose weight and those who experienced early weight regain were all counseled for their dietary habits. In the latter group of patients, the amount of weight regain (in kilograms) was calculated by subtracting the lowest BW reading from the final BW reading taken. Those patients were scheduled for GCTV to measure the residual gastric volume (RGV). Guided by Deguines et al. [14], we used the value of 225 cc as the RGV threshold (the volume above which the risk of LSG failure is high). The correlations between the amount of weight regain and each of the four parameters [preoperative BW, preoperative BMI, distance between the pylorus and the staple line, volume of the stomach on GCTV (RGV)] were studied. Logistic regression analysis was then conducted in order to identify the predictors of weight recidivism. Values in our study were expressed as means or as numbers (%). Correlation between variables was performed using Spearman rank correlation
Inclusion criteria
Exclusion criteria
• Age of 16–60 years at the time of surgery
• Active alcohol or substance abuse
• BMI ≥40 or BMI ≥35 with a significant obesity-related co-morbidity
• Active gastric ulcer disease
• Failed adequate conservative program (diet, exercise and/or medication) for at least 6 months • Psychological stability/motivation and acceptance of surgical risks
BMI body mass index
• Gastroesophageal reflux disease (GERD) with a large hiatal hernia • Previous bariatric surgery • Pregnancy or lactation • Significant longstanding heart/lung disease or other severe systemic disease
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coefficient (r). A P value
