Laparoscopic Sleeve Gastrectomy

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Laparoscopic Sleeve Gastrectomy

Sleeve gastrectomy is a novel approach for the surgical treatment of morbid obesity. Weight loss is achieved through restriction and endocrine action. This method was first developed using an open technique by Dr Doug Hess as a part of bariatric duodenal switch (DS) surgery. Doug Hess performed a sleeve gastrectomy (SG) as the first step of his two-stage procedure based on BMI (kg/m2) in 1988. Gastric sleeve (SG) resection is the proper first-stage surgery in patients with a BMI between 45–60, cirrhosis, and excessive visceral fat.

Two-stage surgery is a suitable approach for very obese patients where both operations can be performed laparoscopically. The first stage is a major gastrectomy SG, in which a gastric sleeve is created over the bougie along the greater curvature of the stomach from the distal sinus to the tingling angle. When sufficient weight loss was achieved after 6–12 months, a BPD/DS or RYGB is performed as the second stage of the procedure. The success of SG performed as the first stage and the observations that this success continued in the follow-up phase indicated that this procedure can be used alone. So, although SG is performed as the first stage of this two-stage surgery, in recent years, it has been performed as a restrictive bariatric surgery since most patients can lose and maintain their weight. SG procedure is a restrictive surgery because it reduces the volume of the stomach. However, vomiting is absent or moderate compared to other restrictive bariatric procedures (AGB, VBG, etc.).

Many scientific studies showed that direct laparoscopic RYGB can be safely performed as an alternative to two-stage surgery in extremely obese patients. However, this surgery should be performed by an experienced team.

“LAPAROSCOPIC SLEEVE GASTRECTOMY IS THE MOST PERFORMED OBESITY SURGERY IN THE WORLD.”

The 2007 and 2009 international consensus studies reported that SG is an effective method that can be safely used as a restriction procedure in patients with decreased serum ghrelin levels and decreased appetite. Most of the cells that secrete ghrelin in the stomach are located in the fundus. Serum ghrelin levels decrease and appetite decreases after extensive resection. The popularity of this method is increasing worldwide as it yields good results in both short term and long term. Another reason for getting SG surgery was when a gastric band was removed and needed revision. Some clinics perform SG as revision surgery if the initial SG is unresponsive.

Preoperative Evaluation

With an evaluation of medical history and current physical condition, any endocrine problems should be determined and, if present, treated. In addition to the routine preoperative evaluation, the patient should be examined by an endocrinologist or internist using abdominal ultrasonography, and spirometry. If the ultrasound finds stones in the gallbladder, a cholecystectomy should also be performed in the same session. This is because gallstone complications often occur with excessive weight loss after gastric sleeve surgery.

Patients are examined by an anesthesiologist several days before gastric sleeve surgery. The obesity treatment decision should be given according to the patient’s diet and mental state. Restrictive surgical methods such as gastric banding may not be successful if the patient consumes high-calorie liquid beverages, has a high sugar intake, and snack frequently. Restrictive and partial malabsorption procedures such as gastric bypass should be preferred. RYGB is preferred for bariatric surgery in the United States and Canada; however, the use of AGB increased in the United States has in recent years. Gastric banding is preferred in Europe and Australia, but RYGB is rising in Europe in recent years. SG, on the other hand, is being used more and more frequently around the world.

Early Follow-Up

Regardless of the procedure used in this surgery, regular patient follow-up and complete patient compliance are the most important criteria for a positive response. Intermittent compression of the lower extremity should be applied with a single-dose prophylactic antibiotic, low-molecular-weight heparin, and elastic bandages or compression stockings. Oral intakes may start 12 hours after the procedure. Patients can take water and tea orally on the day of surgery. We mobilize all patients undergoing laparoscopic surgery 4–6 hours or 2 hours when mechanical ventilation is no longer needed.

The prophylactic administration of low molecular weight heparin should be continued for 1 month.Flash Cure Med recommends low-calorie liquid drinks for the first two weeks, soft food for the third week, and very firm solid foods from the fourth week onwards. To prevent cholelithiasis, administer 10 mg/kg of ursodeoxycholic acid twice daily for 3 to 6 months, depending on the degree of weight loss. Postoperative follow-up of morbidly obese patients is similar to that of oncology patients. This means frequent and close follow-ups are required. Clinical and laboratory follow-up is needed 1 week, 1 month, 3 months, 9 months, and 1 year after the hospital discharge. Plus, we encourage you to consult your clinic monthly via phone.

LSG Complications (0-29%)

Leakage
Bleeding from the suture line
Spleen injury
Liver injury
Pulmonary embolism
Atelectasis
Acute kidney failure
Urinary infection
Delay in gastric emptying (Gastric dilatation, prolonged vomiting)
Subphrenic abscess
Incision site infection
Bronchogastric fistula
Hernia
GER

Treating Complications of Sleeve Gastrectomy

Bleeding: A conservative approach is preferred.

Leakage (leakage from resection line): Absorbable support material can be placed at the tip of the cartridge, as well as sutures and fibrin glue are used to prevent this complication. However, some scientific studies have reported that suturing the resection line can cause ischemia and leakage due to suture rupture. Although suturing the resection line does not prevent leakage, it can prevent bleeding. Leaks should be checked with an intraoperative methylene blue or air test. At Flash Cure Med, we carry out air tests regularly.
At the end of the surgery, bring the tip of the calibration tube to the distal oesophagus, inflate it, fill the resection line with SF in the Trendelenburg position, check for air bubbles, and expel the air in the oesophagus. Remove the stomach and calibration tube. Do not use NS probes. At our clinic, we usually place a silicone drain on the resection line. Suturing, drainage + TPN, and endoscopic clipping are the recommended approaches in the treatment of leaks. In the late period, fibrin glue, stenting, and Roux loop surgery can be performed.

Impacts on Comorbidities and Weight Loss

According to BAROS (Bariatric Analysis and Reporting Results System) assessment at 1-year follow-up, Gastric sleeve resection results were 30% excellent, 34.5% good, 9.5% good, and 13% bad.

According to scientific research, SG was effective in reducing the weight loss rate by 43.6% after one year, 46.6% after two years, and 33.9% after three years.

In a prospective study, the average success rate for weight loss following bariatric surgery was found to be between 50 and 60 percent at a 5-year follow-up. Patients who received VBG, AGB, and RYGB experienced an 80% improvement in obesity-related comorbidities throughout their 3-year follow-up.

With AGB, morbid obesity is decreased by 40.3% and overall obesity by 36%.

Morbid obesity can lead to serious health issues. Following bariatric surgery, even a 10% weight loss considerably lowers blood sugar, blood pressure, cholesterol levels, and sleep apnea. Hepatic steatosis is another unfavourable outcome of morbid obesity (fatty liver). If untreated, it leads to liver cirrhosis, fibrosis, inflammation, and hepatocellular cancer. Gastric sleeve resection helps morbidly obese patients with non-alcoholic hepatic steatosis. Over 50–60% of people with morbid obesity have metabolic syndrome, which includes hypertension, dyslipidemia, and impaired glucose tolerance. Following bariatric surgery, metabolic syndrome has been seen to drop from 58% to 3% of patients.

Weight loss, hypertension, type 2 diabetes, sleep apnea, gastric reflux, varicose veins, urinary incontinence, female hormone problems, pseudobrain tumours and improvement in joint osteoarthritis are the most common effects of bariatric surgery. With weight loss, the patient’s self-confidence and work performance increase.

According to scientific reports, 77.2% of type 2 diabetes, 71.7% of hypertension, 61% of hyperlipidaemia, 95% of sleep disruption, 67.7% of peripheral oedema, 45% of depression, as well as ENECLEMIC 8 syndrome, sleep & gastroesophageal reflux were treated with laparoscopic surgery. The benefits and drawbacks of the laparoscopic sleeve gastrectomy and adjustable gastric band (AGB) procedures are as follows: no risk of leaving a foreign object in the body, no need for modification, and no band-related issues (such as migration). This procedure is irreversible and there is no bleeding or leakage. Unlike RYGB, gastroduodenoscopy is an effective option. Because the pylorus is retained, there is no change in how oral drugs are absorbed, no risk of internal hernia, no dumping syndrome, and no anastomosis. SG prevents malabsorption and preserves the natural integrity of the gastrointestinal tract.

The Place of Sleeve Gastrectomy in Metabolic Surgery

Type 2 diabetes (T2DM) is a chronic condition that needs a pricey lifestyle, including food, exercise, and medicine. Although bariatric surgery’s curative role in treating obesity in type 2 diabetes was first noted 30 years ago, its use in the direct treatment of type 2 diabetes is relatively new. AGB, RYGB, SG, and BPD-DS operations are currently recognized metabolic procedures.

We believe that such patients should have the right to live without diabetes. The endocrinologist’s evaluations, the patient’s preference, and the surgeon’s approach are factors that affect the choice of the metabolic surgery method to be applied.
The most efficient strategy to avoid and treat major obesity-related issues and life-threatening complications are the surgical treatment of morbid obesity. When there are significant hazards related to obesity and non-surgical weight loss techniques are ineffective, surgery is recommended. Surgical methods can improve an overweight person’s quality of life and extend their lifetime in a highly safe and effective manner. Surgical techniques have been developed and used frequently. Today, more and more laparoscopic procedures are performed. The majority of individuals who are at high risk for obesity benefit from these operations.

The gastric bypass (GBP) is the most successful procedure option if restrictive surgical procedures (VBG, AGB, etc.) are unsuccessful. The LSG might be chosen if the AGB fails or if late issues arise that need ligament excision. If the SG fails, some clinics prefer to perform a revision SG.

Considerations for Applications

Patients who have comorbidities, a BMI of 40 or higher, or a BMI of 35 or lower are suitable for SG. Surgery is the most efficient approach to losing weight and maintaining the reduced weight. Surgical interventions should only be carried out by experienced surgeons in hospitals with multidisciplinary teams with experience and intensive care units with ventilators. Liposuction is frequently done for cosmetic reasons to remove undesirable subcutaneous fat lumps; however, liposuction does little to help with the comorbidities associated with obesity.

The diet of the patient should be taken into account when choosing the treatment technique. There are types of surgery that should be evaluated first for those who snack frequently and consume excessive calorie liquids.
Currently, there is no ideal surgical technique.

A two-step method should be preferred for patients with cardiopulmonary diseases that pose a high risk. Gastric balloon procedure is less beneficial for patients who are at high risk for anaesthesia, including those with impaired wound healing, severe lung disease, unstable coronary artery disease, and others. One of the primary contraindications is pregnancy or giving birth within two years.