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Obesity Surgery, 16, 1323-1326
Laparoscopic Sleeve Gastrectomy as Treatment for Morbid Obesity: Technique and Short-Term Outcome Paul E. Roa, MD1; Orit Kaidar-Person, MD1; David Pinto, MD1; Minyoung Cho, MD, PhD1,2; Samuel Szomstein, MD, FACS1; Raul J. Rosenthal, MD, FACS1 1
Department of Surgery, The Bariatric Institute and Section of Minimal Invasive Surgery, Cleveland Clinic Florida, Weston, FL, USA; 2Department of Surgery, College of Medicine of Korea University, Seoul, Korea Background: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) and laparoscopic adjustable gastric banding (LAGB) are the most commonly performed surgical procedures for weight reduction in the United States. Currently, laparoscopic sleeve gastrectomy (LSG) is being explored. The aim of this study was to assess the safety and short-term efficacy of LSG as a treatment option for weight reduction. Methods: Data of all patients who underwent LSG for treatment of morbid obesity between November 2004 and March 2006 and completed the 3- and 6month follow-up visits at the time of the study, were retrospectively reviewed. Data collected included demographics, operative time, length of stay, postoperative complications, and degree of weight reduction. Results: Of the 62 patients who underwent LSG performed by two surgeons, the data of 30 patients (7 males and 23 females) were further analyzed. Mean preoperative BMI was 41.4 (33-59) kg/m2. Mean operative time was 80 min (range 65-130). Mean hospital stay was 3.2 days (range 2 to 25). Mean weight loss at 3 and 6 months following the procedure was 22.7 kg and 30.5 kg respectively, and mean % excess weight loss (EWL) was 40.7 and 52.8, respectively. Three patients were considered to have mild complications, and one patient had a major complication that necessitated surgical intervention. There was no mortality. Conclusions: In the short-term, LSG is a safe and effective treatment option.
Key words: Laparoscopy, sleeve gastrectomy, morbid obesity, bariatric surgery, restrictive procedure Reprint requests to: Raul J Rosenthal, MD, FACS, Director, Bariatric Institute and Head, Section of Minimally Invasive Surgery, Department of General & Vascular Surgery, Cleveland Clinic Florida. 2950 Cleveland Clinic Blvd, Weston, Fl 33331, USA. Fax: (954) 659-5256; e-mail:
[email protected]
© FD-Communications Inc.
Introduction Laparoscopic sleeve gastrectomy (LSG) is a relatively new option being used in the treatment of morbid obesity. This procedure was originally published by Marceau et al1 in 1993 as a restrictive part of a duodenal switch malabsorptive operation, in an attempt to improve the results of biliopancreatice diversion, without performing a distal gastrectomy. Recently, LSG has been proposed as the first-step in the treatment of super-obese patients or in patients with high operative risk before performing more complicated procedures such as laparoscopic biliopancreatic diversion with duodenal switch (BPD-DS) or laparoscopic Roux-en-Y gastric bypass (LRYGBP).2-8 Currently, LRYGBP and laparoscopic adjustable gastric banding (LAGB) are the most commonly performed bariatric operations in the United States. Other procedures such as LSG that might be associated with lower morbidity rates and require less postoperative follow-up are being explored. Evidence has suggested that LSG significantly reduced ghrelin levels due to resection of the gastric fundus, which is the predominant area of human ghrelin production.9,10 Thus, LSG might have a physiological advantage to achieve sustained weight loss over other restrictive procedures such as LAGB or vertical banded gastroplasty, that do not influence the ghrelin-producing cell mass.9 The aim of this study was to assess the safety and short-term efficacy of LSG as an alternative treatment option for morbid obesity. Obesity Surgery, 16, 2006
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Roa et al
Methods After institutional review board approval, data of all patients who underwent LSG for the treatment of morbid obesity at the Cleveland Clinic Florida between November 2004 and March 2006 was retrospectively reviewed from our database. Only the data of patients who had completed their 3- and 6month follow-up visits at the time of the study. were further analyzed. Data collected included demographics, operative time, length of stay, postoperative complications, and weight loss. Weight loss was expressed as the percentage of excess weight loss (%EWL). The ideal weight was derived from the Metropolitan height and weight tables using the mid-weight for a medium-frame.11 Patients were selected for LSG on the basis of: 1) patient preference; 2) high-risk; 3) contraindications for gastric bypass (inflammatory bowel disease, severe small bowel adhesions; 4) low BMI (≥35) without co-morbidities; 5) as a step to allow other operations to be performed (e.g. joint replacement); 6) heavy smokers; and/or 7) patients on anticoagulants.
flated the abdominal cavity to 15 mmHg pressure. The liver was retracted cranially, the gastroesophageal (GE) junction was exposed 6 cm proximal to the pylorus, and the short gastric vessels on the greater curvature were taken down with the Harmonic scalpel™ (Ethicon) up to the GE junction. A 52-Fr bougie was placed trans-orally into the pyloric channel, and with a 4.1-mm and 3.5-mm Endopath® (Ethicon) linear cutter, the stomach was transected vertically creating a gastric tube. The estimated capacity of the created gastric sleeve was 150 mL. A 2-0 silk suture was run over the staple-line for hemostasis and prevention of leaks. A drain was placed in the subhepatic space near the staple-line. The resected stomach portion was placed in a specimen bag and extracted through the supraumbilical trocar site. All trocar sites were sutured and injected with local anesthetic. After the procedure, patients were transferred to the recovery room and later to the intermediate care unit. All patients underwent a Gastrografin® study on the first postoperative day.
Results Surgical Technique After induction of anesthesia and endotracheal intubation, 7 trocars were used (Figure 1). The abdominal cavity was accessed through a 1-cm supraumbilical incision using the Optiview trocar™ (Ethicon EndoSurgery, Cincinnati, OH). Carbon dioxide insuf-
Figure 1. Trocar placement.
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Of the 62 patients who underwent LSG performed by two surgeons (SS and RJR), only the data of 30 patients (7 males and 23 females) who had completed their 3- and 6-month postoperative follow-up visits at the time of the study were further analyzed. Two patients had undergone LAGB prior to the LSG. Mean preoperative weight was 118.2 kg with a mean body mass index (BMI) of 41 (range 33-59) kg/m2 (Tables 1 and 2). At 3 months following LSG, mean weight loss was 22.6 kg, and at 6 months 30.5 kg. The mean %EWL was 40.7 and 52.8 at 3 and 6 months respectively. Patients with lower BMI (50 kg/m2) achieved a better %EWL (60 vs 50). Mean BMI decreased to 34 and 32 kg/m2 at 3 and 6 months respectively (Table 3). Mean operative time was 80 min (range 65-130). All the operations were completed laparoscopically. Mean hospital stay was 3.2 days (range 2-25). Four patients had early postoperative complications. Three patients were considered to have mild complications, and were readmitted due to mild dehydration. In one patient, a leak from the sta-
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Laparoscopic Sleeve Gastrectomy for Morbid Obesity Table 1. Patients’ demographics and preoperative weight Variable Gender (F:M) Age (yr) Weight (kg) BMI (kg/m2)
Mean 23:7 40 (17-69) 118.5 (86.8-168.2) 41.4 (33-59)
Table 2. Patients’ preoperative body mass index (BMI) Classification
n (%)
Moderate obesity BMI 30
