Laparoscopic Gastric Sleeve for Morbid Obesity

Laparoscopic Gastric Sleeve for Morbid Obesity

Raul J. Rosenthal

Samuel Szomstein


In patients with morbid obesity, surgery is the most effective treatment for weight loss and improvement in some comorbid conditions. Although a number of surgical techniques exist, laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic adjustable gastric banding (LAGB) are currently the most commonly performed bariatric procedures in the United States. Sleeve gastrectomy (SG), a relatively new surgical approach, was initially conceived as a restrictive component of the biliopancreatic diversion and duodenal switch (BPD-DS) in the era of open bariatric surgery. With the advent of minimally invasive surgery in the late 1980s, laparoscopic sleeve gastrectomy (LSG) has been proposed as a first-step procedure in high-risk patients followed by a second-step laparoscopic LRYGB or BPD-DS, and recently as a standalone bariatric approach. LSG combines the principles of gastric restriction and hormonal appetite suppression by removing the fundus of the stomach and thus the majority of the oxyntic glands that produce the appetite-stimulating hormone ghrelin. This approach creates a “sleeve” or tubular stomach along the lesser curvature.

Evolution of Sleeve Gastrectomy As A Primary Procedure for Weight Loss in Morbid Obesity

SG was first described in 1988 when Scopinaro’s technique of biliopancreatic diversion with distal gastrectomy and gastroileostomy was modified by Hess and simultaneously by Marceau as a restrictive component of the BPD-DS procedure during the time when bariatric surgery was conducted via laparotomy (open surgery). In 1999, 10 years after the introduction of minimally invasive surgery, LSG was performed as a first-step procedure in high-risk patients to be followed by a second-step LRYGB or laparoscopic BPD-DS. The original idea conceived by Gagner et al. was to allow super-morbidly obese patients to lose weight and decrease their operative risk by allowing some comorbid conditions to go into remission. It was also meant to make the approach of a BPD-DS technically easier via laparoscopy. In reality, it was the introduction of laparoscopy and the knowledge that weight loss correlates directly with the resolution of comorbidities that created this new concept of a “step approach” in bariatric surgery. Due to the high incidence of wound infections and hernias seen in patients undergoing bariatric surgery via laparotomy, it would have been inconceivable to perform an open SG as a first step and return for a second time to perform a definitive approach.

As experience with the technique increased, the role of LSG evolved and many began to consider it as a primary restrictive bariatric procedure. Early reports of prospective and retrospective studies were encouraging.

Indications and Patient Selection

In most institutions, LRYGB, LAGB, and LSG are offered to all patients. Following the National Institutes of Health recommendations, most centers in the United States recommend LRYGB as the procedure of choice or the “gold standard” in patients with a body mass index (BMI) > 40 kg/m2 with or without comorbidity. As experience with LSG increases, attempts are being made to define indications for LSG as a first or final step. Most centers concur that with LSG, a substantial amount of evidence exists to recommend LSG in the presence of serious contraindications or poor surgical candidates for LRYGB, BPD-DS, and LAGB (Table 1).

Additional indications include patients with liver cirrhosis (without severe portal hypertension), dense adhesions of small bowel (high risk for bowel obstruction after RYGBP or BPD-DS), large recurrent abdominal wall hernias in the presence of obesity (lower incidence of recurrence after weight loss), and expected complex colorectal surgery in patients with diverticular or inflammatory bowel disease (easier placement and tolerance of ostomies as well as technically advantageous to perform pull-through procedures).

More controversially, LSG may have a role in patients with a low BMI of 30 to 35 kg/m2 who have metabolic syndrome. The latter should be considered investigational and conducted only under Institutional Review Board protocol.

The potential benefits of performing sleeve gastrectomy include that due to its “relative” technical simplicity (a simple but not easy procedure), it can be performed laparoscopically in high BMI patients (super-super-morbid obesity). Also, minimal follow-up is required when compared to other well-established procedures such as LAGB, as there is no need for adjustments with LSG. When compared to RYGBP/BPD-DS, there are no marginal ulcerations, internal herniation, gastrogastric fistulae, or micronutrient malabsorption. It is an attractive option for patients with chronic conditions such as Crohn’s/celiac disease or ulcerative colitis, which preclude extensive intestinal surgery. In addition to all of these benefits, LSG appears to be an excellent treatment option for kidney or liver transplant candidates since it does not change the anatomy and maintains intact absorption of immunosuppressive drugs.

As mentioned, LSG provides an effective decrease in operative risk and alleviates technical difficulties when implemented as a first-stage procedure for super-obese and high-risk patients. It can be converted to a malabsorptive procedure such as BPD-DS, or to an LRYGB in case of failure of weight loss and/or severe gastroesophageal reflux disease (GERD).

When contemplating bariatric surgery indications, factors that are taken into consideration by surgeons and patients are the following: patient age, BMI, associated comorbid illnesses, efficacy, morbidity, and insurance coverage. There is also a so-called “patient preference” when discussing surgical options. LSG is attractive to the patients who do not want to undergo anatomic rearrangement of their intestinal anatomy (RYGBP or BPD-DS) or placement of an implanted device (LAGB).

There are, to our knowledge, no studies that discuss in detail the contraindications for LSG. Based on the review of most series discussed in this manuscript, four clinical scenarios can be considered as absolute contraindications. The first scenario is the patient with severe and documented GERD; the performance of LSG in this clinical scenario could worsen the GERD by creating a high-pressure system with intermittent distal obstruction (the pylorus) in a patient who already has an insufficient lower esophageal sphincter. Furthermore, LSG
removes the gastric fundus and, as a result, an antireflux procedure becomes impossible for those patients who are not candidates for RYGBP or BPD-DS.

Table 1 Indications and Contraindications of Laparoscopic Sleeve Gastrectomy in Morbidly Obese Patients

Indications procedure Characteristics Contraindications
Two-stage procedure   Absolute
First step in super-super-morbidly obese patient Followed by RYGB or BPD Severe and documented GERD
First step to a non-bariatric second procedure Low BMI of 35–40, followed by hip replacement, recurrent incisional hernia, pull through procedure for ulcerative colitis, renal/liver transplantation Barrett’s esophagus
Single-stage procedure   Liver cirrhosis and severe portal hypertension
Final step in ASA IV morbidly obese patient Low EF, heart/liver/kidney transplant recipient Relative
Final step in poor candidate for LRYGB or BPD-DS Smoker; Warfarin Perioperative risk of cardiac complications
Final step in extremes of age Adolescents; Elderly age ≥70 y Poor myocardial reserve
Final step in a high-risk stomach Chile, Colombia, Japan: high incidence of gastric cancer Significant chronic obstructive airways disease or respiratory dysfunction
Patient preference/refusal to undergo anatomic rearrangement of their intestinal anatomy or placement of an implanted device   Noncompliance of medical treatment
Low BMI of 35 to 40 with comorbidity   Psychological disorders of a significant degree
Final step in Crohn’s/Celiac disease or UC   Significant eating disorders
BMI 30 to 35 with the metabolic syndrome Under protocol only Large hiatal hernias
Other indications: Liver cirrhosis, dense adhesions of small bowel, expected complex colorectal surgery in patients with diverticular disease, huge abdominal hernia, necessity to continue specific medications (immunosuppressant, anti-inflammatory).    
D, biliopancreatic diversion; EF, ejection fraction; GERD, gastroesophageal reflux disease; LRYGB, laparoscopic Roux-en-Y gastric bypass;RYGB, Roux-en-Y gastric bypass; UC, ulcerative colitis.

The second clinical scenario is the patient with Barrett’s esophagus. There is scientific evidence that for morbidly obese patients with severe GERD, gastric bypass is the procedure of choice. Additionally, removing the greater curvature of the stomach with LSG eliminates the portion of the stomach that can be potentially used as a graft (interposition) in those cases when an esophagectomy is indicated.

The third clinical scenario is the patient with liver cirrhosis and severe portal hypertension (Child’s Class B/C). In this clinical scenario, LSG has a high risk for complications and mortality as does any other surgical procedure. In addition, the removal of the short gastric vessels will decrease the capacity and drainage of the portal venous system, potentially worsening the hypertension. It would be of interest to evaluate LSG as a treatment option for morbidly obese patients with liver cirrhosis and portal hypertension who undergo a decompressive procedure, such as transjugular intrahepatic portosystemic shunt, followed by LSG.

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Aug 2, 2016 | Posted by in GENERAL SURGERY | Comments Off on Laparoscopic Gastric Sleeve for Morbid Obesity

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