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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 35  |  Issue : 2  |  Page : 128-133

Role of laparoscopic sleeve as an initial operation for super obese patients


1 Department of General Surgery, Faculty of Medicine, Benha University, Benha, Egypt
2 Ahmed Maher Teaching Hospital, Phoniatric Unit, Faculty of Medicin, Ain Shams University, Cairo, Egypt

Date of Submission09-Feb-2018
Date of Acceptance19-Mar-2018
Date of Web Publication17-Aug-2018

Correspondence Address:
Dr. Khalid A.O. Japr
25 Abdelrahman Amin Street, Alna’am, Cairo, 11311
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/bmfj.bmfj_20_18

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  Abstract 


Background Obesity is recognized widely as an epidemic disorder, and morbid obesity is the most dangerous among all types of obesity. In past years, sleeve gastrectomy has evolved as a single-stage procedure for the treatment of morbid obesity, but still super obese patients (BMI >50–60) have high risks of being operated on (anesthesia and postoperative risks).
Objective The aim was to investigate the initial weight loss (6 months postoperatively) in super obese patients after laparoscopic sleeve gastrectomy (LSG).
Patients and methods A prospective study included 20 patients. All patients underwent LSG as an initial and solitary bariatric procedure over a 12-month period in Kasr Alaini, Benha University, and Ahmed Maher teaching hospitals during the period from October 2016 till September 2017.
Results We identified 20 patients who underwent LSG as a primary weight loss procedure and met the inclusion criteria during the study period. Mean age at the time of LSG was 36.68±12.17 years (range: 18–58 years), and most patients were female [N=15 (75.0%)]. At the time of LSG, mean weight was 142.4±15.02 (range: 115–173), mean height was 162.4±8.58 (range: 148–185), and so mean BMI was 53.26±2.93 (range: 50–59). After a median follow-up of 6 months, overall percentage total weight loss was 41.61±11.31% (24–59.39), with a decrease in mean BMI from 53.26±2.93 preoperatively to 31.44±5.99 at the end of the study.
Conclusion According to the benefits shown through weight loss and the minimum complications, our data along with previous studies strongly support the use of LSG among super obese patients as a first and standalone operation, as it is a safe and feasible option.

Keywords: bariatric surgery, gastric, laparoscopy; morbid (super) obesity, restrictive sleeve gastrectomy, weight loss


How to cite this article:
Mohamed MM, Zidan AM, Salama RS, Japr KA. Role of laparoscopic sleeve as an initial operation for super obese patients. Benha Med J 2018;35:128-33

How to cite this URL:
Mohamed MM, Zidan AM, Salama RS, Japr KA. Role of laparoscopic sleeve as an initial operation for super obese patients. Benha Med J [serial online] 2018 [cited 2018 Dec 13];35:128-33. Available from: http://www.bmfj.eg.net/text.asp?2018/35/2/128/239191




  Introduction Top


The incidence of obesity has significantly increased worldwide. Surgery has proven to be the most effective long-term treatment for sustained weight loss and improvement of comorbidities in morbidly obese patients [1].

Severely obese patients with high BMI (>50–60), life-threatening co-morbidity, and extremely poor quality of life have the greatest potential of direct benefit from bariatric surgery [2]. However, they often carry an operative risk of morbidity and mortality that is two to three times greater than the typical morbidly obese patient, often rendering them ineligible for bariatric surgery [2].

Recognizing that surgically induced weight loss is the most effective method of improving co-morbidity and, consequently, operative risk, a two-stage approach was created to laparoscopic Roux-en-Y gastric bypass (LRYGBP). The first stage involves laparoscopic sleeve gastrectomy (LSG) and the second stage is conversion to LRYGBP [3].

LSG is associated with much less surgical intervention than LRYGBP, and was therefore considered a suitable selection as a preliminary stage [3].

LSG is a relatively new procedure for weight loss with lower surgical risks, which is particularly suitable for those patients at highest risk for surgery, either because of their comorbidities or their weight [4].

LSG is being explored as a viable surgical option for treating morbid obesity, after simply being considered the first step of a staged procedure in super obese/high-risk patients to allow some weight loss before a LRYGBP or biliopancreatic diversion-duodenal switch procedure [4].

With the revelation that patients experience safe weight loss after LSG, interest in using this procedure as a bridge to more definite surgical procedures has risen [4].

Outright reported benefits of LSG include the low rates of complications, the avoidance of foreign material, the maintenance of normal gastrointestinal continuity, the absence of malabsorption, and the reduction of gherlin producing mass, accounting for its superiority to other restrictive bariatric surgical procedures [4].

The surgical treatment of obesity in the high-risk, high-BMI (>50, 60) patient remains a challenge.

Major morbidity and mortality in these patients can approach 38% and 6%, respectively [5].

New criteria for surgical treatment of morbid obesity could be considered for morbidly obese adolescents, where the adolescent is physically incapacitated and socially and psychologically disadvantaged [5]. Age or skeletal maturity should not be used to limit their opportunity for long-term weight loss and improvement in their quality of life through surgery [5].


  Patients and methods Top


Study population and data collection

Our study is a prospective study that included 20 patients. All patients underwent LSG as an initial and solitary bariatric procedure over a 12-month period in Kasr Alaini, Benha University and Ahmed Maher teaching hospitals during the period from October 2016 till September 2017. The study was approved by the Research Ethical Committee and an informed consent was obtained from each participant before enrollment in the study. Patients were considered appropriate candidates for this study if they met the following criteria:
  1. Willing to give consent and comply with the evaluation and treatment schedule.
  2. Patients who have BMIs of 50 kg/m2 or more ([Table 1]).
    Table 1 Differences between weight distributions throughout the periods of follow-up and preoperatively

    Click here to view
  3. Appropriate nonsurgical measures have been tried but have failed to achieve or maintain adequate, clinically beneficial weight loss for at least 6 months.
  4. All patients are receiving or will receive management in a specialist obesity service.
  5. All patients are generally fit for anesthesia and surgery.
  6. All patients commit to the need for long-term follow-up.


All patients needed to demonstrate the absence of significant psychopathology that could limit their ability to understand the procedure and comply with the medical, surgical, and/or behavioral recommendations.

Surgical procedure

Anesthesia and patients’ and doctors’ position

Operations were performed under general anesthesia with the patient in supine position and the surgeon positioned between the legs of the patient (French position), after applying compression stockings on the patient lower legs. The patients were firmly secured to the operating table to allow for placement in the anti-Trendelenburg position as required.

Carbon dioxide insufflation was used to create pneumoperitoneum by veress needle in the left hypochondrium for all cases maintaining a 15-mmHg intra-abdominal pressure and flow rate between 2 and 2.5 l/min.

After creation of pneumoperitoneum, a five-trocar approach was used ([Figure 1]).
Figure 1 Trocar placement.

Click here to view


A 5-mm subxyphoid trocar serves as a liver retractor. One 12-mm trocar between the subxyphoidal 5-mm trocar and the umbilicus serves as an optical port, and additional two 12-mm working ports are placed 3–4 cm under the left and right costal margin pararectal, where the left one serves as a channel for the linear stapler. Another 5-mm left subcostal anterior axillary line trocar is used for stomach traction.

The greater gastric curvature vascularity is divided starting 4–10 cm from the pylorus and proceeding to the angle of His ([Figure 2]).
Figure 2 Division of gastric arteries.

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The gastroepiploic vessels along the greater curvature of the stomach and the short gastric vessels are divided using the LigaSure device (Covidien, Cincinnati, Ohio, USA) and the harmonic shears (Harmonic scalpel; Ethicon Endo-Surgery Inc., Cincinnati, Ohio, USA). Dissection of adhesions between the back of the stomach wall and the pancreas is performed. A 36-Fr calibrating bougie was introduced by the anesthesiologist into the stomach and advanced along the lesser curvature into the pyloric channel and duodenal bulb. The stomach was divided using the Echelon Compact Linear Stapler (Ethicon Endo-Surgery Inc.).

A combination of green reload (4.1 mm) for the first firing and golden reloads (3.7 mm) for the upper stomach is used. An ∼5–10-mm cuff of stomach was left at the level of the angle of His to avoid including the esophagus with the staple line ([Figure 3]).
Figure 3 Final view.

Click here to view


Afterward, a leak test with methylene blue was used to check the integrity of the stapler line.

Eventually, the calibrating bougie was removed.

The resected stomach was removed in all cases via the 12-mm port without the need to enlarge it further.

Routine placement of suction drain at the operative bed was done in all cases.

Statistical analysis

The clinical data were recorded on a report form. These data were tabulated and analyzed using the computer program SPSS (statistical package for the social sciences; SPSS Inc., Chicago, Illinois, USA), version 20:

Descriptive data

Descriptive statistics were calculated for the data in the form of the following:
  1. Mean and SD for quantitative data.
  2. Frequency and distribution for qualitative data.


Analytical statistics

In the statistical comparison between the different groups, the significance of difference was tested using one of the following tests:

(1) Paired t-test was used to compare mean of variables in different time periods of quantitative data.

A P value less than 0.05 was considered statistically significant (*), whereas greater than 0.05 was statistically insignificant. P value less than 0.01 was considered highly significant (**) in all analyses.

Preoperative weight is defined as the weight immediately before LSG.

As there is no standardized method to report weight-related calculations in adolescents, we utilized percentage total weight loss (%TWL) for all patients using the following calculations:




  Results Top


We identified 20 patients who underwent LSG as a primary weight loss procedure and met the inclusion criteria during the study period. Mean age at the time of LSG was 36.68±12.17 years (range: 18–58 years), and most patients were female [N=15 (75.0%)] ([Table 2]).
Table 2 Distribution of the studied group according to personal data

Click here to view


At the time of LSG, mean weight was 142.4±15.02 (range: 115–173), mean height was 162.4±8.58 (range: 148–185), and so mean BMI was 53.26±2.93 (range: 50–59) ([Table 2]).

Weight loss outcomes

After a median follow-up of 6 months, weight loss results following LSG have shown promising findings among adolescents in recent years [6],[7], as well as our study states this finding in super obese patients, as shown in [Table 2].

Percentage total weight loss outcomes

In fact, studies have found that LSG, in comparison with LRYGBP, had better results in terms of excess weight loss [8]. This is particularly important in the adolescent population, as LSG has been reported to have a lower incidence of adverse effects as compared with the more extensive LRYGBP. Patients undergoing LSG, in comparison with LRYGBP, have easier dietary compliance, less vitamin disturbances, and a better quality of life with the additional benefit of having an anatomically preserved gastrointestinal tract [8].

Moreover, %TWL in our study shows great increase in the short-term outcome after 1, 3, and 6 months. Starting by mean 11.17 in first month to mean 24.88 in third month and ending by 41.61 at last month (sixth) ([Table 3]).
Table 3 Differences between percentage total weight loss distributions throughout the periods of follow-up

Click here to view


In our study, BMI showed marked changes in the 6-month follow-up after the surgery, starting with mean BMI of 53.26 preoperatively, then 47.6, 40.6, and ending with 31.4 in the last month of the study. This clarifies the great results of the LSG in super obese patients even so as a standalone operation ([Table 4]).
Table 4 Differences between BMI distributions throughout the periods of follow-up and preoperatively

Click here to view



  Discussion Top


Obesity has nowadays become a major medical and social problem of most countries [9].

Several contributing factors have been attributed to this obesity epidemic including increases in caloric intake, changes in the composition of the diet, decreasing levels of physical activity, and changes in energy intake versus energy expenditure [10],[11].

Morbid obesity is expanding worldwide [12], and increasing levels of obesity are associated with increasing risk of comorbidities and of death [13].

In addition, psychosocial morbidities secondary to obesity are also well reported and include social marginalization, decreased self-esteem, and decreased quality of life [11].

Because of the rise in obesity among adolescents, several nonsurgical treatments have been investigated. These include dietary modification, physical activity, behavioral modification, and pharmacotherapy. Most of these interventions, however, have led to unsatisfactory short-term and long-term results [14].

Bariatric surgery for morbidly obese persons has been applied increasingly in the past 40 years. Obesity is accepted as a disease with awareness of its seriousness. Moreover, the concept of obesity as a disease and recognition of its metabolic adverse effects are not realized by many people. Yet, worldwide obesity is increasing, now to epidemic proportions [15].

Over the past 20 years, bariatric surgery has come to play a significant role in confronting this problem, using either restrictive or mixed restrictive and malabsorptive techniques [16],[17]. LSG has become an increasingly popular restrictive surgical procedure for the treatment of morbid obesity [17],[18]. As such, the utilization of weight loss surgery for severely obese pediatric patients has increased in recent years [19].

Laparoscopic adjustable gastric banding and LRYGBP are among the most common weight loss operations performed among adolescents [6],[14],[20].

However, recent studies have shown that these operations have a high potential for serious complications [14].

Although long-term comparative data among the three operations are lacking, recent data have shown an increase in the use of LSG in the adolescent population [19].

As we see, several studies have shown LSG to be an effective first-line treatment for morbid obesity in adults [21], and also, weight loss surgery among adolescents, however, remains far less studied and utilized, given the inadequate results of nonsurgical weight management in adolescents [22].

The recent Teen-Longitudinal Assessment of Bariatric Surgery consortium, however, published results showing significant improvement in weight and comorbid conditions after a follow-up of 3 years among adolescents who underwent LSG [22].

We report similar outcomes following LSG as a first-line surgical therapy in patients with BMI 50 or more (super obese) of different age and sex, after following them up for 1, 3, and 6 months.


  Conclusion Top


In the current study, we found LSG to be an effective weight loss treatment for super obese patients. After a median follow-up of 6 months, overall %TWL was 41.61±11.31% (24–59.39), and decrease in mean BMI was from 53.26±2.93 preoperatively to 31.44±5.99 at the end of the study.

According to the benefits shown through weight loss and the minimum complications, our data along with previous studies strongly support the use of LSG among super obese patients as a first and standalone operation, as it is a safe and feasible option. So in our view, LSG should be strongly considered as a primary surgical treatment option for all super obese patients.

Acknowledgements

First and foremost, all thanks go to ALLAH, the most graceful and most merciful.

The author is greatly honored to express his deepest respect and gratitude to Professor Dr Mohamed Mahmoud Mohamed, the eminent Professor of General Surgery, Benha University, for his faithful supervision, understanding, help, and encouragement in initiating and completing this work.

The author is also much obliged and grateful to Professor Dr Ahmed Zidan, Professor of General Surgery, Benha University, for his continuous guidance and valuable advice throughout this work, and also for his great help and support throughout all the steps of this work.

Moreover, the author would like to thank Dr Refaat Salama, Assistant Professor of Surgery, Benha University, for being the first one to support and indeed being a real backbone for this work to have been completed.

The author is also obliged to all the professors, the seniors, and colleagues for their continuous and endless encouragement in this work.

Eventually, all thanks go to the author’s family for supporting him from the beginning to the very end.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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