OBES SURG (2010) 20:271–275 DOI 10.1007/s11695-009-0038-x
CLINICAL RESEARCH
Laparoscopic Sleeve Gastrectomy as a Single-Stage Bariatric Procedure Tarik Sammour & Andrew G. Hill & Parry Singh & Anudini Ranasinghe & Richard Babor & Habib Rahman
Received: 20 July 2009 / Accepted: 17 November 2009 / Published online: 8 December 2009 # Springer Science+Business Media, LLC 2009
Abstract Background Laparoscopic sleeve gastrectomy is increasingly being used as a stand-alone procedure in bariatric surgery, with medium-term follow-up data now emerging. We present our early experience in patients with a mean body mass index (BMI) in the super-obese range. Methods Review of prospectively collected data for the first 100 patients who underwent laparoscopic sleeve gastrectomy at Counties Manukau District Health Board between March 2007 and July 2008. Results One hundred patients were identified, with a mean age of 43 years (range, 20–60 years). Maori and Pacific Islanders made up 31% of the patient subset. Patients had a mean BMI of 50.3 kg/m2 (range, 34.5–72.8 kg/m2). Fortyfive patients were super-obese. The median hospital stay was 2 days (range, 1–7 days). Mean follow-up was 12.0 months (range, 0.9–23.3 months). Mean excess weight loss was 62.9% (range, 7.2–129.0%). Twenty-five percent of patients were diabetic and 45% of patients were hypertensive pre-operatively. Diabetics and hypertension resolved or improved in 72% and 60% of patients, respectively. There was a major complication rate of 7%, including three staple-line leaks (one requiring laparotomy), two staple-line bleeds (one requiring laparotomy) and one infected haematoma. There were no deaths. T. Sammour (*) : A. G. Hill : A. Ranasinghe : R. Babor : H. Rahman Department of Surgery, South Auckland Clinical School, Middlemore Hospital, Private Bag, 93311 Otahuhu, Auckland, New Zealand e-mail:
[email protected] T. Sammour : A. G. Hill : P. Singh Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
Conclusions In this public hospital setting, laparoscopic sleeve gastrectomy has achieved satisfactory weight loss results with an acceptable complication rate in the medium-term. Keywords Sleeve gastrectomy . Obesity . Bariatric . Diabetes . Weight loss . Gastric . Gastroplasty
Introduction Laparoscopic sleeve gastrectomy (LSG) is increasingly being used as a stand-alone procedure in bariatric surgery with medium-term follow-up data emerging [1–3]. The major advantages of this procedure appear to be a lower post-operative morbidity than laparoscopic roux-en-y gastric bypass (LRYGB) and bilio-pancreatic diversion [4, 5], with superior weight loss compared with laparoscopic adjustable gastric banding (LAGB) [6, 7]. There also appears to be significant hormonal (ghrelin) suppression after LSG, which is not demonstrated after LRYGB and LAGB in direct comparison studies [6–8]. There have been favourable reports of weight loss for up to 3 years after LSG [7, 9], although the durability of this weight loss remains to be demonstrated by longer-term follow-up [9, 10]. Obesity is a significant problem in the South Auckland region of New Zealand, with a prevalence of 33.0% according to the latest New Zealand Ministry of Health data [11]. A publicly funded bariatric service has been in operation at Counties Manukau District Health Board since early 2007. Laparoscopic sleeve gastrectomy is offered as the primary surgical procedure. We conducted a review of prospectively collected data for the first 100 patients that underwent this procedure in our centre.
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Methods
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parametric continuous measures, the t test was used for comparisons (P40 or ≥35 kg/m2 with comorbidities were considered for surgery. Other criteria included a requirement to cease smoking, establish a regular exercise programme, lose at least 0.5 kg per week between outpatient appointments, and maintain a low calorie Optifast diet (Société des Produits Nestlé S.A., Vevey, Switzerland) for 3 weeks pre-operatively.
Results Demographics One hundred patients underwent LSG between March 2007 and July 2008. Patients had a mean age of 43 years (range, 20–60 years). Eighty patients were female and 20 were male. Sixty percent of the patients were Caucasian, with Maori and Pacific Islanders making up 19% and 12% of the patient subset, respectively. Pre-operative Patient Characteristics
Surgical Technique The patient was placed in Lloyd–Davis position and pneumoperitoneum achieved by the open Hassan technique. Using 4-port laparoscopy, the bursa minor was entered by dissection of the gastro-colic ligament. Dissection along the greater curvature was started 4 cm from the pylorus. A 36 French calibration bougie was placed trans-orally along the lesser curvature of the stomach and a stapled vertical gastrectomy performed parallel to this, starting 4 cm from the pylorus. Selective staple-line reinforcement with a continuous running suture was used for haemostasis. A leak test using air insufflation was performed.
Patients had a mean pre-operative BMI of 50.3 kg/m2 (range, 34.5–72.8 kg/m2), and 45 patients were super-obese (BMI>50). Mean pre-operative weight was 140.8 kg (range, 96.7–211.9 kg), and mean on-table weight was 126.4 kg (range, 86.0–185.0 kg). Twenty-five patients were diabetic on medication (all but one patient were type II diabetics), and five of these required subcutaneous insulin for glucose control. Forty-five patients were taking antihypertensive medication; 25 patients were taking statin medication, and 17 patients had obstructive sleep apnoea requiring continuous positive airway pressure (CPAP) therapy.
Data Collection
Surgery and Post-operative Course
A review of prospectively collected data was conducted for the first 100 patients who underwent LSG at Counties Manukau District Health Board (between March 2007 and July 2008). Data collected included demographic data, preoperative weight/BMI, on-table weight/BMI, comorbidities (as defined by medical treatment), intra-operative variables, post-operative complications, mortality, excess weight loss, resolution of obesity-related comorbidities (defined as reduction or resolution of medical therapy) and patient satisfaction as measured by a linear analogue scale from 1 (very dissatisfied) to 10 (very satisfied). All data were entered prospectively into a custom-designed database. Approval for the surgery and prospective audit was granted by the institution's clinical board.
The surgery was performed by two surgeons (H.R., R.B.). Mean operating time was 91.6 min (range, 52.0– 256.0 min), with one case converted to open and no patients requiring an intra-operative blood transfusion. Patients had a median hospital stay of 2 days (range, 1– 7 days) and a mean follow-up period of 12.0 months (range, 0.9–23.3 months). There was a major complication rate of 7%, including one iatrogenic transected stomach after the calibration bougie migrated superiorly on firing the stapler. This necessitated conversion to laparotomy and primary repair. There were three post-operative staple-line leaks all of which were in patients without staple-line reinforcement. One patient had a distal staple-line pinhole leak and was managed with laparotomy and over-sewing of the staple-line. The other two patients had proximal leaks, one of which was managed with endoscopic stenting and the other with a radiologically placed percutaneous drain on day 22 post-operatively. There were two post-operative staple-line bleeds (one requiring laparotomy and the other re-laparoscopy to
Statistics Statistical analyses were performed using SPSS (Statistical Package for the Social Sciences version 13.0 for Windows, Lead Technologies Inc, USA). Results are presented as mean (range) or median (range) as appropriate. For
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establish haemostasis) and one infected haematoma requiring laparotomy. There were no deaths during the follow-up period. The minor complication rate was 3%, with one patient undergoing a normal diagnostic laparoscopy postoperatively on the day of surgery for a suspected bleed, one critical stricture requiring endoscopic dilation and another patient developing a delayed umbilical hernia requiring open mesh repair.
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medications completely, and nine of 17 patients with obstructive sleep apnoea were able to stop CPAP. Patient Satisfaction Median patient satisfaction score was high at 10 (range, 3–10).
Discussion Weight Loss Mean percentage excess weight loss (%EWL) if patients with a major complication were included was 62.9% (range, 7.2–129.0%). Excluding patients with a major complication, mean %EWL was similar at 63.2% (range, 7.2–129.0%; see Fig. 1) and mean absolute weight loss was 41.1 kg at 1 year (range, 4.4–78.2 kg). Excess weight loss in patients with a pre-operative BMI
