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tomy (LSG) is considered a principal laparoscop- offering patients considerable excess weight loss
ic bariatric procedure, mainly due to the many (%EWL)17-19. Boza et al20 reported, after 1000
advantages it possesses. consecutive cases, that the %EWL at 1, 2 and 3
years had been 86.6%, 84.1% and 84.5% respec-
tively. Similarly, Rawlins et al21 found a %EWL
Mechanisms of action of 86% at 5 years. In contrast to these very
promising results, most publications agree that
The LSG is essentially a restrictive bariatric patients undergoing LSG achieve a 60%EWL at
operation. Weight loss is achieved by drastically 5 years22-27. After an initial high %EWL, most
reducing the gastric volume, which in turn leads series report some weight regain after the second
to reduced food intake. In addition, a series of year19. Respectively, Himpens et al25 and D’Hondt
hormonal changes occurring postoperatively in et al28 observed that patients regain weight after
bariatric patients, contribute to decreased appe- 5 years, with the % EWL dropping below 60%.
tite, reduced food intake and long-term weight However, Sarela et al29 reported a %EWL of 69%
loss (Figure 1)11, 12. Ghrelin, a hormone produced at 9 years, the longest follow-up to date.
primarily by the oxyntic cells of the fundus of
the stomach during fasting, stimulates appetite by
increasing the expression of the orexigenic hypo- Nutrient deficiencies
thalamic neuropeptide Y (NPY)11. By removing
the gastric fundus, patients undergoing sleeve It is well documented that obese patients are
gastrectomy have markedly decreased levels of generally malnourished, mainly due to a non-var-
ghrelin and suppressed appetite respectively13. ied diet high in fats and carbohydrates and low
Peptide YY (PYY), a hormone produced post- in quality protein products, dairy and vegetables.
prandially from the gut, inhibits the release of Most nutrient and micronutrient deficiencies per-
NPY and has an anorectic effect14. PYY is nota- sist postoperatively in patients undergoing bar-
bly increased after sleeve gastrectomy, leading iatric surgery and as a result multivitamin sup-
to prolonged satiety and reduced food intake13. plementation is necessary for these patients30,31.
Glucagon-like peptide-1 (GLP-1) is secreted from However, nutritional deficiencies vary greatly
the enteroendocrine L-cells in the intestine as a between different bariatric operations, with LSG
response to food indigestion. GLP-1 stimulates having only a minimal impact on the nutrient
insulin release, inhibits glucagon secretion and status22,32,33. Similarly to other types of bariatric
has a satiating effect. Both rapid gastric emptying procedures, most commonly observed nutrient
and postprandial hyperglucagonemia observed deficiencies like iron, folate and thiamine persist
after sleeve gastrectomy lead to increased GLP-1 postoperatively, but can be easily resolved with
levels15, 16. a daily multivitamin supplementation22,32-35. Iron
deficiency and anemia in particular, commonly
seen in bariatric patients, are also present after
Weight loss after LSG LSG. However, the risk for anemia after LSG is
lower compared to the other type of procedures,
A major advantage of LSG is that despite when the iron supplement is administered post-
being an easy, quick and safe bariatric proce- operatively33,36. Vitamin D deficiency is common
dure, it is also an effective surgical technique, among obese patients due to malnutrition and
limited sun exposure. Postoperative hypovita-
minosis D, however, is not common after LSG
due to loss of adipose tissue and adequate supple-
mentation22,32. Respectively vitamin B12 deficien-
cy is also not common after LSG as compared to
gastric bypass and BPD22,32,34,36,37. Vitamin B12 is
absorbed in the terminal ileum when banded to
intrinsic factor, which is produced from the pari-
etal cells in the antrum and duodenum. As com-
pared to other malabsorptive bariatric operations,
Figure 1. Hormonal changes occurring postoperatively af- where the duodenum is bypassed, the uptake of
ter LSG. vitamin B12 is not disturbed in LSG32,36.
4931
I. Kehagias, A. Zygomalas, D. Karavias, S. Karamanakos
4932
Sleeve gastrectomy, a review
4933
I. Kehagias, A. Zygomalas, D. Karavias, S. Karamanakos
sular, leaks present early on the first two postop- tients, before a prospective second-stage bariatric
erative days80. Based on this fact, some surgeons procedure (mainly RYGB) is performed, within
have adapted their technique, in order to reduce two years18.
the risk of a mechanical failure of the stapling It is important that all patients undergo com-
line. A number of different reinforcing materials prehensive interdisciplinary assessment by a team
have been introduced and many studies have tried of specialists experienced in obesity manage-
to provide evidence for their use81-84. Yet, staple ment and bariatric surgery. Sleeve gastrectomy
line invagination with a simple running sero-se- candidates should undergo routine preoperative
rous suture, with or without the addition of an assessment, like any other major abdominal sur-
omental patch, could efficiently control bleeding gery. Laparoscopic SG adheres to the indications
and attempt to reduce postoperative leaks without and guidelines of all other bariatric procedures94.
increasing the cost67,72,85. Choi et al86 and Glaysher Therefore, it should be offered to morbidly obese
et al87 have published important meta-analyses patients with metabolic syndrome and to patients
and review studies in order to answer the critical with a BMI of 35 kg/m2 and associated co-mor-
question of staple line reinforcement. However, bidities61,94.
while current evidence suggests that staple-line Super obese patients, with BMI > 50 kg/m2,
reinforcement may reduce the incidence of post- can be offered LSG as this procedure seems to be
operative leaks and other associated complica- also effective for this group of patients95-97. How-
tions, it does not significantly reduce bleeding ever, super obese patients tend to regain weight
complications and cannot be recommended as a after the first 12 months of follow-up, while main-
standard technique61,86. taining the improvement in co-morbidities98,99.
In order to identify potential leaks or defect Considering the above some authors believe that
sites of the staple line, many surgeons test the LSG should be the first step of a 2-step procedure
integrity of the newly-formed gastric pouch by for the management of super obese patients9,61.
introducing air or methylene blue at the end of the Laparoscopic SG seems to be a feasible and
operation. Nevertheless, a negative test does not safe procedure for high-risk surgical patients. It
exclude a postoperative leak and many authors can be used as a safe first surgical procedure in
do not perform these tests at all88,89. A simpler order to achieve rapid weight loss in high-risk pa-
test to discover a potential staple line defect is tients who need to undergo a second non-bariatric
to inflate the resected stomach with air using a procedure such as knee replacement, nephrec-
regular syringe89. tomy or spine surgery100. Chaudhry et al101 and
Some authors have proposed that the measure- Tariq et al102 have also published promising data
ment of the resected gastric volume at the end regarding morbidly obese patients with end-stage
of the procedure can safely predict the overall organ failure who successfully underwent LSG.
%EWL. A resected gastric volume of more than Laparoscopic SG has proved to be technically
500-1100 ml has been associated with %EWL feasible and effective in obese patients awaiting
of ≥ 50%50,90. However, the resected gastric vol- kidney transplantation, for adequate pre-trans-
ume is greater in patients with high preoperative plantation weight loss, thus improving their ac-
BMI91. Finally, it is important to send for routine cess to transplantation103. Sleeve gastrectomy can
histological examination all gastric specimens. be also used as a post-transplantation bariatric
In about 8% of the cases unanticipated findings procedure in kidney recipients, because by re-
warranting further clinical follow-up may be re- taining the intestinal continuity the uptake of im-
vealed, like H. pylori gastritis, autoimmune gas- munosuppressants is not disturbed104. Obese com-
tritis with a microcarcinoid formation, intestinal pensated cirrhotic patients can also tolerate LSG
metaplasia or even neoplasia92. well. Laparoscopic SG can be safely performed in
cirrhotic patients, with low risk for postoperative
complications, improving their metabolic syn-
Indications and contraindications drome and reducing hepatic steatosis105,106.
Inflammatory bowel disease (IBD) is con-
Laparoscopic SG should be considered a pri- sidered a contraindication for bariatric surgery.
mary bariatric procedure or the first stage of a However, in a study from Steed et al107 more
2-step approach for the management of morbidly than 18% of IBD population found to be obese.
obese patients18,59,61,93. In the later, LSG has been Furthermore, overexpessed obesity-related cyto-
used to treat initially super obese or high-risk pa- kines play a significant role in the development
4934
Sleeve gastrectomy, a review
4935
I. Kehagias, A. Zygomalas, D. Karavias, S. Karamanakos
issues or infection acutely impair the gastric tion with or without CT-guided percutaneous
wall healing72. In order to avoid leaks, tissues drainage of the abscess131. Endoscopic stenting
should be handled carefully and devices like after percutaneous drainage of an abscess is a
staples, electrocautery or other surgical equip- valid treatment option for a proximal leak61,128,131.
ment should be used rationally72,126. A number The endoscopic use of fibrin glues, plugs or clips
of studies investigated the use of staple line has also been reported, although their efficacy
reinforcing materials81-84. Recent studies suggest is not proven72,131. The surgeon should wait for
that staple-line reinforcement may reduce the in- at least 12 weeks with conservative therapy be-
cidence of postoperative leaks86,87. Nevertheless, fore considering a reoperation to address a leak.
a running sero-serous suture that invaginates Revision of the procedure and conversion to
the staple line from the angle of Hiss to the another operation are possible options61. In the
midpoint of the transection, and a second con- case of a re-intervention, conversion to gastric
tinuous suture from this point to the end, with bypass, Roux-en-Y, or total gastrectomy can be
or without an omental patch may be adequate in performed61,132,133.
order to reduce leak rate67,72,85. During stappling, The development of GERD or the worsening
it is also very important to compress the gastric of reflux symptoms has been reported by some
tissue carefully for a prolonged time (e.g. 30 sec) authors as a late complication of LSG. Kehagias
before firing in order to reduce tissue edema127. et al22 and Himpens et al28 reported a peak of
Additionally, a nasogastric tube can be left in GERD symptoms in the first year which de-
the newly-formed gastric pouch for 24 hours to clined during the first triennium. Himpens et al28
reduce intraluminal gastric pressure128. observed a second peak after the sixth year28.
Many authors routinely perform upper gas- The intact pylorus, the removal of the antrum,
trointestinal swallow studies postoperatively in the severely restricted gastric capacity and the
order to evaluate the presence of an early leak, disrupted motility could create stasis and induce
between the first and third postoperative day. or exacerbate reflux symptoms119. When the re-
However, the sensitivity of these studies is low section is not close enough to the esophagus, a
and a negative test does not exclude the pres- neofundus could form, which could also aggra-
ence of a leak126,128-130. Although gastric leaks vate the reflux symptoms due to increased gastric
can be accurately diagnosed with computed to- acid production119. Additionally, the presence of
mography, CT scans should only be performed a neofundus could also deteriorate GERD when
when the clinical suspicion is high and not for it is migrated intrathoracically, especially in the
screening129,130. If a leak occurs, the management presence of an untreated hiatal hernia. However,
is crucial for the outcome. The clinical presen- several studies have shown that the relationship
tation can vary greatly between patients and between GERD and LSG is multifactorial. Such
while most patients are completely asymptom- factors are an alteration of the lower esophageal
atic, complications like peritonitis, septic shock, sphincter pressure, reduction of gastric compli-
multi organ failure and death have been reported. ance and emptying, increased sleeve pressure,
Burgos et al126 observed that tachycardia can accelerated gastric emptying and the effect of
be the initial sign of a leak. Patients with he- weight loss117,134. Although GERD is considered
modynamic instability or those who cannot be a relative contraindication for LSG, some mod-
controlled using conservative measures require ifications have been proposed to address this
intervention. Postoperative leaks can be catego- problem. Identification of a hiatal hernia intra-
rized into acute (within 7 days), early (within 1-6 operatively should be persistent and if found, it
weeks), late (after 6 weeks) and chronic (after 12 should be repaired61. This can effectively control
weeks) in regard to the time of presentation61. the reflux symptoms135. An antireflux sleeve gas-
An acute fistula can be repaired surgically if the troplasty consisting of a combination of vertical
defect can be identified126. However, primary gastroplasty and Nissen fundoplication has been
repair of a fistula is associated with high rates proposed by Fedenko and Evdoshenko with en-
of recurrence. In late fistulas simple primary couraging results136. However, if reflux symptoms
repair of the defect is not possible due to chron- occur, proton pump inhibitors should be the first
ic inflammation and concomitant presence of line of treatment61.
an abscess128. Stable patients can benefit from Gastric stenosis and strictures following LSG,
conservative treatment, like nothing by mouth, although uncommon, can occur especially after
intravenous antibiotics and total parental nutri- some time137,138. Stenoses occur either distally,
4936
Sleeve gastrectomy, a review
4937
I. Kehagias, A. Zygomalas, D. Karavias, S. Karamanakos
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