Safety, effort and findings of gastric sleeve operation for morbidly obese patients

Safety, effort  and findings  of gastric  sleeve operation for morbidly obese patients

WesamAmr MD; AshraflsmaelMD; MorsiMohamedMD, Yahia ZakariaMD

Departmrnt of General  Surgery, Ain Shams University, Cairo, Egypt.

Background: Sleeve gastrectomy  is a surgical technique  to treat morbid obesity  by both restrictive  and  probably  hormonal  action.  Originally  developed  as a first  stage to  gastric bypass, it is more and more performed as a sole procedure. Therefore it is important to report results on weight loss and reduction in co-morbidity.

Patients and methods:  Sixty morbidly obese patients (15 male, 45 female) were studied with a mean age 35 ±10.9, mean BMI of 47.4 ± 7.8 kglm? All were evaluated and managed by sleeve gastrectomy from January 2009 to January 2012 in the General Surgery Department, Zagazig University Hospitals, 30 patients were associated with co-morbidity. Preoperative demographic data, operative data and postoperative follow up at 3ms, 6ms, 12ms were collected.

Results:  Laparoscopic  sleeve gastrectomy (LSG) was done in 59 patients with conversion to open  in one  patient;  major  postoperative  complication  was  bleeding  (1pt.).  The  mean operative time ofthe procedure including  anesthesia  was 155 ±18.5  min. The mean hospital stay was 3.1±.6days. The mean reduction in weight was 50 kg, reduction inBMJwas BMI of 17

±4.9kgl m2 and reduction in %EWL was 48. 7± 15. Complete resolution was 76. 7% in 23 cases of co-morbidity patients.

Conclusion: Sleevegastrectomy  can be performed safely with acceptable complication rates and good weight loss with good efficacy on the co-morbidity management.

Key words: Sleeve gastrectomy, morbid obesity, weight loss.

Introduction:

Bariatric surgery remains the only effective treatment for  inducing  and maintaining satisfactory weight  loss and reducing weight­ related  co-morbidities for the morbidly  obese patient.!

Bariatric  surgery includes a variety of procedures  performed  on  people   who   are obese.  Weight  loss  is achieved by reducing the size of the stomach with an implanted medical  device (gastric  banding) or through removal  of a portion  of the  stomach  (sleeve gastrectomy   or    biliopancreatic   diversion with duodenal switch)  or by resecting andre routing the small intestines to a small stomach pouch  (gastric  bypass surgery).2

The  laparoscopic  sleeve   gastrectomy (LSG) is a mainly restrictive procedure designed   to  decrease   appetite   by  reducing

the  ability   of  the  stomach  to  distend   and producing  the   sensation  of   fullness   with minimal  oral intake.3

Since  its  introduction, the  indication has broadened from  the  first  step   in  treatment of  the   super-obese  to   a  single   procedure for a wider range of patients suffering from obesity.4-5

As the sleeve  gastrectomy is theoretically a  more   definite   procedure   than   the   band without  the  disadvantages of mal-absorptive bypass and the initial results reported are promising, it is necessary to report results on weight  loss and co-morbidity.6 Therefore we report  our  experience with  LSG,  evaluating the safety  and efficacy  of this procedure as a standalone operation.

Patients and  methods:

From   January    2009   to   January   2012,

60  obese  patients,  aged  19  to  50  years,  fit for surgery, were submitted to LSG in the department of general surgery at Zagazig University Hospital. LSG was indicated for weight  reduction  only  for  patients  with  a BMI  >40 kg!m2 or  >35 kgfm2  with  severe co-morbidity  related to the  obesity  e.g. diabetes,      hypertension,      hyperlipidemia, and osteoarthritis. All patients had made reasonable attempts at weight management with diet, exercise and behavior modification. The patients were informed about the aim of the study and gave their written consent.

Data  collected  included  patient demographic data, past medical history, co­ morbidities, weight and BMI, operative data (operating time, blood transfusion, blood loss, complications, conversion, and drainage), duration of hospital stay and morbidity/ mortality rates. All patients were followed up in terms of weight loss and for co-morbidity improvement  post-operatively  at 3ms,  6ms, and 1 year.

Surgical  procedure:  After  admission  all

patients had preoperative evaluation including clinical examination mainly blood pressure, chest and heart examination, laboratory investigations mainly complete blood picture, plasma blood glucose levels, liver and kidney function, complete lipid profile.

Prophylactic      anti-coagulant      measures

were done in all patients in the form of elastic stocking and subcutaneous low molecular weight heparin (Clexan 40mg) taken 6 hours before the procedure.

Positioning      of      the      patient:      After

prophylactic       antibiotics       and       general anesthesia    were      administered    with      oro­ tracheal  intubation,  the  patient  was  placed in  the  supine  anti-Trendelenburg   split-leg position, also called French position. A Foley catheter  was  inserted  to  monitor  the  urine output and an 18-Fr Oro-gastric tube was also inserted to decompress  the stomach to have an adequate working space. Prophylactic dose of antibiotics was parentrally administered to all patients approximately  30 to 60 minutes before the procedure  and another  one gram was added every two hours of operation time.

Operative technique: After an established pneumo-peritoneum  5 ports were introduced

into the abdominal cavity. Dissection began on the greater curvature, 6 em from the pylorus, this   point   was  usually   marked   by   some adhesions  on the dorsal side of the stomach and ventrally  by small veins in a so- called crows' feet shape. The gastro-colic ligament along  the  greater  curvature  of the  stomach was opened  using an impedance coagulator (Ultra-sonic  dissector) Harmonic scalpel and was  freed  as  far  as  the  cardia-esophageal junction  at the root  of the  left pillar  of the hiatus. The short gastric vessels close to the spleen  were carefully  coagulated separately. Guided  by  a 34-Fr tube  illuminated  tip  by small  lamp manually  inserted  in the bougie till its tip with a wire connected to a battery, guiding us to the proper site of the bougie, a laparoscopic  linear  stapler  (Endo GIA) was introduced   into  the  peritoneal  cavity   and was positioned so that it divided the stomach parallel to the orogastric tube along the lesser curvature. The instrument was fired, reloaded, and the maneuver was repeated; 1 sequential

4.8/60-mm green cartridge was used to staple the  antrum  followed  by  3  or  4  sequential

4.2/60-mm gold cartridges, to staple the remaining gastric corpusand fundus and followed by 3.5/60mm blue cartilage 1-2cm below the osephago-gastric junction, the diameter of the gastric tube was therefore 34

F. After 5 or 6 firings of the stapler, the greater curvature was completely detached from the stomach  and  retrieved  through  one  of  the 15mm port site. A methylene  blue test (150 ml of methylene blue fluid was introduced by a nasogastric tube) was performed to exclude staple-line leakage. In case of a staple line bleeding an Endo-clip was used to clip the bleeding  point.  The gastric suture  line was not  systematically  reinforced  except  in the case of bleeding or positive methylene  blue test, drain was routinely placed. Concomitant cholecystectomy was done in eight female patients due to gall stones.

Postoperative   course:  All  patients  were given intravenous fluids 35 ml I kg body weight during the first postoperative day then according to their fluid chart in the subsequent days.  Naso-gastric  tube  was  removed  after one  day.  Early ambulation  was  advised  on  

Figure (1): Rluminated bougie.

Figure (3): Division of the vascular supply using Hannonic scalpel.

Figure (5): Rlumination guided us to the proper site of bougie in the stomach.

Figure (7): Sequential liner stapler using golden cartilage.

first postoperative day. Drain was removed on 3rd  postoperative day after ensuring no leak. Proton pump inhibitors were given I.V early postoperative and continued orally for

2 months after dischruge. SC low moleculru·

Figure (2): Dissection began on the greater curvature, 6 em from the pylorus.

Figure (4): Division of the short gastric vessels.

Figure (6): First Endo GL4liner stapler with green cartilage.

Figure (8): The resected part of the stomach.

weight hepruin was continued postoperative,

6 hours after the operation (if no bleeding) by dose (clexan 40mg) evety day till the patient  was  dischru·ged. Dtinki.ng cleru· fluids was begun on the third postoperative

Table (1): Patients preoperative characteristics of the studied cases (60 cases).

Table (2): Preoperative body mass index (BMI).

Table (3): Prevalence of preoperative obesity related co-morbidities  at base line.

Table (4): Operative data.

day. The patients were  discharged  2-5 days postoperative according to postoperative course.

Follow     up    three     and     six   month's

current weight minus his or her ideal body weight, and the %EWL is the ratio of weight lost at each time point over the total excess

weight. Complete blood picture, fasting blood

postoperative  visit:  Body  weight,  BMI  and        glucose, serum creatinine and complete lipid percentage  of excess  weight  loss (%EWL).         profile. One  year  postoperative  visit:  Body

Excess weight was calculated as the patient's        weight,   percentageof    excess   weight   loss

Table (6): Changes  of weight and BMI among the studied group before and after operation.

Table (7): Prevalence  of co-morbidities related to morbid obesity before and after surgery.

(%EWL), and BMI, complete blood picture, fasting blood glucose, serum creatinine and complete lipid profile.

Statistical analysis: The data were collected presented and analyzed using SPSS-PC (version 10) software. Comparisons between measures   (Mean   ± SD)   were   done   using paired t-test for two paired groups; also, qualitative categories were expressed in the form of frequency and percentage. The test results  were considered  significant  when P.value was < 0.05.

Results:

Sixty patients were included in the study;

45 females (85%) and 15 males (15%). Their ages ranged from 19 to 50 years with a mean age  of  35± 10.9  years.  Preoperatively   the weights of our patients ranged 108 kg to 195 kg with a mean weight of 140.2 ± 3.2kg. BMI ranged from 37.3 to 70.3 kg/m2 with a mean BMI of 47.4 ± 7.8kgf m2 Table (1,2).

In our study, 30 patients (50%) had co­ morbidities.  12 patient were diabetic,  7 patients  had  hypertension,   8  patients  had hyperlipidemia    and   3   had   osteoarthritis Table (3).

In   our   study   sleeve   gastrectomy   was done by laparoscopy  in 59 patients  (98.3%) with conversion to open surgery in one case (1. 7%). The intra-operative blood loss ranged from (100 cc to 300 cc) with a mean blood loss of (129.4 ± 10.8cc). The operation time ranged  from  (200 to  240 minutes)  in early cases and (135 to180 min) in the late cases, with  a  mean  operation  time  of  (155± 18.5 min).   Postoperative   hospital   stay   ranged from (2 to 5 days) with a mean hospital stay of (3.1± 0.6days) Table (4). The incidence of early  intra-operative   complication  included one  case  (1.7  %)  of  uncontrolled  bleeding from the site of short gastric vessels that was explored for its management. Laparoscopic cholecystectomy was done in eight female patients   (13.3%)   who  suffered   from   gall stones.

In our study no mortality and the rate of early postoperative  complications  was 6. 7% in 4 patients,  1 with postoperative  bleeding who needed exploration,  1 with wound infection (in the patient explored for bleeding) and two with paralytic ileus. We didn't report other complications as gastric leak, organ injury, bowel ischaemia, marginal ulcer, and dumping syndrome.

In     our     study,    two     patients     needed exploration, one ofthem was female patient 48  years  old  with  intra-operative  bleeding during dissection and division of short gastric vessels who needed conversion to open sleeve gastrectomy and the other one was also female patient 21 years old who presented at night of the day of the operation with hypotension and  abdominal   rigidity   , the  patient  was treated conservatively  with intravenous fluid and blood transfusion  without  improvement so  she was explored  at the  morning of day 1 postoperative  by  left  sub-costal  incision, hemoperitoneum  with bleeding from the site of the short gastric and subphemic hematoma was found. Reinforcement  ofthe stapled line with polyprolene to avoid leak with traction of the stomach during the exploration, evacuation  of the hematoma,  ligation of the bleeding  vessels at the area of short gastric

were done and with closure with tube drain.

The patient was discharged at the day 5 postoperative. In our study, blood transfusion was needed in two patients who needed exploration, about 3 units of packed RBCs to each one. Table (5).

There was a highly statistical significant difference  between  mean  scores  of  weight and BMI before surgery and (three, six and twelve)  months after surgery. The mean pre operative  weight  was 140  ± 3.2 kg and one year after operation it was reported to be 90. 3 ± 1.1 kg with a mean reduction in weight of  50 kg which  was statistically  significant (P-value <0.001)the mean pre operative BMI was 47.4kg/m2 and. One year after operation it was reported to be 30.5 kgf m2 with a mean reduction  in  BMI  of  17  ± 4.9kgfm2  which were statistically significant (P-value < 0.001) and  the  mean  percentage  of excess  weight loss was 48.7% ± 15 at one year Table (6).

In our study we had significant reduction in the prevalence of hyperslipidemia,  and diabetes disease One year after surgery there was a highly statistical significant difference in the reduction of fasting plasma glucose levels after surgery among those with diabetes mellitus. While in those without diabetes mellitus,  the  reduction  was not  significant. We had also significant reduction in the prevalence of osteoarthritis Table (7).

We had  observed  that  26 (86.7%)  cases of  patients  with  co-morbidities  had  shown complete resolution (76.7%) in 23 cases and improvement ofthe disease in 3 cases (10%) with  only  4  cases  (13.3%)   continued  the same treatment.  In diabetic patients 8 cases discontinued  the treatment,  2 cases  reduced the doses of the drugs and 2 cases continued the same treatment. In hypertensive  patients

4    cases    discontinued    the    treatment,     1 case  reduced  the  doses  of the  drugs  and  2 cases   continued   the   same  treatment.   All cases of hyperlipidemia and osteoarthritis discontinued the treatment.

Discussion:

Bariatric or weight loss surgery is the only treatment for morbid obesity that confers definitive  weight  loss  at  long-term  follow­

up. In addition to weight reduction there is a strong possibility of amelioration or even cure of various co-morbid conditions associated with obesity.7

LSG is an innovative procedure for the management   of  obesity.  It was  originally developed as a first-stage bariatric procedure to reduce surgical risk in high-risk patients through  the  induction  of  dramatic  weight loss. Analysis of the literature suggests  LSG is efficacious in the short term and may offer certain advantages when compared to the existing options ofLAGB and LRYGB. These advantages include: technical efficiency, lack of an intestinal anastomosis, normal intestinal absorption, no risk of internal hernias, no implantation of a foreign body, pylorus preservation  (prevents  dumping  syndrome), the risk of peptic ulcer is low; and the absorption  of  nutrients,  vitamins,  minerals, and drugs is not altered, and finally LSG may be  considered  the  most  appropriate  option in extremely obese patients.8 Moreover, the entire upper gastrointestinal tract remains accessible    for    endoscopic     assessment.9

LAGB   is  not   associated   with   a  decline of the circulating levels of ghrelin,1o and Karamanakos et al11 showed a higher ghrelin level reduction after LSG than after LGB in a prospective, double-blind study. Concerns remain however, regarding the risks and important   major   complications   associated with LSG including staple line leak (1.17%), post-operative hemorrhage (3.57%), and the irreversibility of LSG.12

It has been suggested that the size of the gastric tube is a factor influencing the degree of weight loss. This may be partly explained by complete resection of the gastric fundus, which contains most of the ghrelin-producing ce1ls.13,14 No consensus, however, has been reached  regarding  the  optimal  dilator  size that should be used to create the lesser curve conduit, with various reports recommending diameters between 32 and 60 F. The antrum has been spared in some papers and removed in others.15 In our study we had spared the antrum.

Undoubtedly  some surgeons  are stapling flush with the bougie at the oesophagogastric junction whilst others are leaving a larger cuff of tissue. Here, we left a 1-2 em cuff of tissue at the oesophagogastric to reduce the leak rate in a region which has potential weakness due to the decussation of esophageal musculature radially over the proximal stomach.15

Rosenthal (2011)16 reported that; the mean patient age was 42 years, with 26% male and 73% female. The mean BMI of the patients was 44± 4.7kg!m2. The mean bougie size was 37F ± 5.92F. The average length of hospital stay  was  3.1  ± 0.93  days.  The  conversion rate was 1.05 ± 1.85%. On average, patients experienced a 1.06% leak rate and 0.35% stricture rate.

Our  study  was  done  on  sixty  patients; the  mean  patient  age  was  35  ± 10.9  years, with 15% male and 75% female. The mean weight of our patients was 140.2 ± 3.2kg and the mean BMI of 47.4 ± 7.8kgf m2. LSG was done by laparoscopy in 59 patients  (98.3%) with conversion to open surgery in one case (1.7%).  Concomitant  cholecystectomy   was done in 8 female patients, and the mean operative  time  was   155   ± 18.5  min.  The average length of hospital stay was 3.1± 0.6 days. All cases in our study were performed with  a 34F bougie with preservation  of the last 5 em of the antrum and a sma11 cuff of gastric tissue of less than 2cm in size at the oesophagogastric junction.

In our study, no mortality occurred and the

rate of early postoperative complications was

6.7% in 4 patients. We reported no gastric leak or organ injury possibly due to certain intra­ operative maneuvers; a running fat retraction stitch  was  easy  and  quick  to  perform  and provided optimum visualization,  particularly for the last crucial firings of the stapler at the fundus.   When  using  the  harmonic  scalpel it was  helpful  to  'rest'  between  bums  and cool the blade on surrounding  omental fat to prevent gastric, splenic or pancreatic injury.17

In our series two cases had been opened, one during the operation due to uncontro11ed bleeding from the short gastric vessels and the other one due to bleeding also who presented with shock at the night of operation and was explored  with  left subcostal  incision. These two patients only needed blood transfusion in

the form of 3 units of packed RBCs for each

Am-ShamsJSurg2014; 7(2):241-250

of them.

The effect of LSG on weight loss was significant in our study, the mean weight reduction was 50 kg after one year, the mean

reduction in BMI was 17 kg/m2 after one year

and  the  mean  percentage of  excess  weight loss  (%EWL) was  40.5%   and  48.7%  at  6 months  and one year respectively.

In a study  conducted  by Cottam  D et al8

involving 126  patients   with  a  preoperative mean   BMI  value  of  65.3  ± 0.8,  the  mean

%EWL after  LSG at one year was 46%. One distant  mortality was encountered, and the incidence  of  major   complications reached

13%. Rosenthal RJ et all8 reported 30 patients

with a mean preoperative BMI value of 41.4. Mean  weight  loss  in this  study  at three  and six  months  postoperatively was  22.7 kg and

30.5  kg  and  mean  %  EWL  40.7  and  52.8,

respectively.

The  degree  of  weight  loss  in  our  series was similar  to that  reported  by Mognoletai19 (EWL  of  41%  at  6  months) who  used  the same  size  of gastric  tube  (34  F), but  it was lower than the results  reported  by Himpenset

aP

The other important endpoint was reduction of medicaments necessary for  an obesity related  chronic  condition. The  influence  on co-morbidity is the most  important endpoint in bariatric  studies. Vidal et aPO. reported the diabetes  and  metabolic syndrome reduction in severely obese patients.  They reported a comparable  effectiveness  for   this   specific group for sleeve gastrectomy as well as gastric by-pass.  In the study of De Paula21 promising results were reported for the laparoscopic interposition of an ileum segment  in to the proximal jejunum. In one study thirty patients with diabetes  were treated  by LSG  and there was a resolution of 63% at 6 months  follow­ up.22 In our study  the resolution rate for osteoarthritis and hyperlipidemia was  100% after 3 months. The resolution rate of diabetes was  66.6%   and  improvement in  16.7%   of total  cases of diabetes.  The resolution rate of hypertension was  57.1%   and  improvement was 14.3%  oftotal cases of hypertension.

Conclusion,     sleeve     gastrectomy     can

be     performed      safely     with     acceptable

complication  rates   and   good   weight   loss. The  percentage excess  weight  loss  reported from this series of up to 48% at one year is encouraging with  improvement of the  main co-morbid diseases.  Debates will continue  as to what is the optimal  bariatric procedure.

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