Laparoscopic Gastric Sleeve Resection Research Articles

A Study of Omentum Reduction on the Improvement of Nausea and vomiting and Gastroesophageal Reflux Symptoms After Laparoscopic Gastric Sleeve Resection.

To investigate the effect of omentum reduction in laparoscopic sleeve gastrectomy (LSG) on the improvement of postoperative nausea and vomiting and gastroesophageal reflux symptoms. A retrospective study was performed on the case data of 198 obese patients who underwent LSG in the Department of Obesity and Metabolic Diseases of Xiaolan People's Hospital of Zhongshan from March 2021 to March 2022 and were divided into omentum reduction group and control group, with 99 cases in each group, and the preoperative body mass index (BMI) of the patients was recorded. Age, gender, comorbidities, and comparative analysis of operation time, blood loss, length of hospital stay, postoperative nausea and vomiting score, gastroesophageal reflux GerdQ score, postoperative pain score, weight, and postoperative complications were analyzed. There were no significant differences in preoperative BMI, age, gender and comorbidities between the two groups (P > 0.05), but there were significant differences in intraoperative blood loss and operation time (P < 0.05). There were differences in postoperative nausea and vomiting scores and VAS pain scores between the two groups (P < 0.05). The GerdQ scores of the omental reduction group were 8.11 ± 2.84 points at 1year, and those in the control group were 7.56 ± 2.67 points, which were 3.97 ± 4.09 points higher than those in the preoperative omentum reduction group and 3.42 ± 3.41 in the control group, with no significant difference (P > 0.05). There was no significant difference in the postoperative excess weight loss rate %EWL and postoperative complications (p > 0.05). Omentum reduction can improve short-term nausea and vomiting after LSG, but it cannot significantly improve long-term reflux symptoms.

STAGED, LAPAROSCOPIC HYBRID EPAULI REPAIR FOR LARGE PARASTOMAL HERNIA – CASE REPORT

Abstract Background Managing large parastomal hernias poses significant challenges due to their high recurrence rates and the elevated risk for peri- and post-operative complications. Method Case report of a successful repair of a large parastomal hernia using a staged minimally invasive, hybrid approach. Results The patient underwent uncomplicated laparoscopic total colectomy in 2016 for ulcerative colitis. Several years later, in 2020, the patient presented to our hospital with a large parastomal hernia with obesity as comorbidity. To address this complex hernia, the patient was referred to the obesity team and underwent laparoscopic gastric sleeve resection in autumn 2021. In 2022, the patient's BMI had decreased to below 30, prompting the decision to proceed with hernia surgery. In May 2022, we performed chemical component separation using 300 units of Botox. Four weeks later, laparoscopic hybrid Epauli repair was undertaken. The laparoscopic component involved reducing hernia contents, abdominal wall dissection with Transversus Abdominis Release (TAR), mesh placement, and closing the posterior layer. Open surgery was interspersed throughout the laparoscopic procedure and at its conclusion. This included temporary stoma closure and reduction, temporary stoma site closure, medial repositioning of the stoma through rectus, excess skin excision, and stoma re-suturing. The patient experienced an uncomplicated recovery. In January 2023, the patient underwent complete abdominoplasty. A one-year postoperative CT scan and clinical control demonstrated a satisfactory outcome. Conclusion For complex and large parastomal hernias, hybrid surgery, combining open and minimally invasive approaches, offers a valuable operative strategy for managing such large hernias.

Laparoscopic gastric sleeve resection for metabolic syndrome (MS) with obstructive sleep apnea-hypopnea syndrome (OSAHS): Report of two cases

To evaluate the therapeutic efficacy of Laparoscopic Gastric Sleeve Resection (LGSR) for patients with metabolic syndrome and Obstructive Sleep Apnea-Hypopnea Syndrome (OSAHS). Two patients with metabolic syndrome and OSAHS received LGSR in our hospital in 2015 and were postoperatively followed up for 3 months to observe relief of the symptoms of Acanthosis Nigricans (AN) and snoring, and changes in metabolism-associated parameters, endocrine hormones and inflammatory factors. The results of 3-month postoperative follow-up observations showed that body weight was reduced and the associated symptoms of AN and snoring were relieved significantly in both patients. Body Mass Index (BMI) and neck and abdominal circumferences were also decreased significantly. Metabolism-related biochemical parameters, inflammatory factors and endocrine hormones including Apnea-Hypopnea Index (AHI), Red Blood Cell Distribution Width (RDW), Fast Blood Glucose (FBG), blood insulin, CReactive Protein (CRP), mean blood pressure and sex hormones all underwent favorable changes in both patients. The clinical outcome of the two patients in our series demonstrates that LGSR is a viable option for the treatment of patients with metabolic syndrome and OSAHS in that it can relieve the snoring symptoms of sleep apnea, improve lipid and glucose metabolisms and endocrine hormone levels in obese patients, and attenuate their chronic inflammation. Keywords: laparoscopic gastric sleeve resection; obstructive sleep apnea-hypopnea syndrome (OSAHS); inflammation; sex hormone.

Comparative Study between Laparoscopic Gastric Sleeve Resection and Laparoscopic Assisted Gastric Plication ; A Retrospective Study

Morbid obesity is a serious condition that can interfere with basic physical functions such as breathing or walking. The individuals who are beyond husky are at more serious danger for sicknesses including diabetes, hypertension, rest apnea, gastroesophageal reflux infection (GERD), gallstones, osteoarthritis, coronary illness and malignant growth. This work means to look at the utilization of laparoscopic gastric sleeve resection versus laparoscopic helped gastric plication in dismal fat patientsIn our examination, the quantity of patients was 30 which were separated arbitrarily into tric Sleeve.Group B: Laparoscopic helped gastric plication. Plication bunch fundamentally had higher overabundance weight reduction and lower cost. With no measurable huge contrasts in regards to post employable complication.Putting into thought that our recorded outcomes are gathered in the initial 6 to a year of the postoperative period, expanded perception of EWL will be our subject in the further examinations. It very well may be reasoned that laparoscopic sleeve gastrectomy and laparoscopic helped gastric plication are viewed as protected and powerful one-stage prohibitive systems to accomplish weight reduction in the beyond husky patients.

Analgesic efficacy of ketamine and magnesium after laparoscopic sleeve gastrectomy: A randomized, double-blind, placebo-controlled trial

BackgroundKetamine and magnesium are antagonists of the N-methyl-d-aspartate receptor, and are valuable adjuvants for multimodal analgesia and opioid sparing. Data are limited regarding the opioid sparing efficacy of the combined intraoperative application of these agents in laparoscopic bariatric surgery. The objective of this study was to compare the postoperative opioid sparing properties of a single intraoperative dose of ketamine versus a combination of single doses of ketamine and magnesium after laparoscopic gastric sleeve resection in bariatric patients.MethodsOne hundred and twenty- six patients were randomly assigned to receive single boluses of ketamine alone 0.5 mg kg−1 IV (ketamine group); combined ketamine bolus of 0.5 mg kg−1 IV and magnesium 2 g IV (ketamine and magnesium group); or placebo. Opioid consumption at 24 h (in morphine equivalents); pain at rest; postoperative nausea and vomiting impact score; sedation scores; and trends of transcutaneous carbon-di-oxide values were analysed.ResultsThe median (inter-quartile range [range]) morphine consumption at 24 h were 32 (24–47 [4.8–91]) mg in the ketamine group, 37 (18–53 [1–144]) mg in the ketamine and magnesium group, and 26 (21–36 [5–89]) mg in the control group and were not significantly different between the groups. There were no differences for all other outcomes examined.ConclusionCombined single intraoperative bolus doses of ketamine and magnesium did not result in postoperative opioid sparing after laparoscopic gastric sleeve resection.

BILOTHORAX: A RARE OCCURRENCE AFTER LAPAROSCOPIC GASTRIC SLEEVE RESECTION

SESSION TITLE: Medical Student/Resident Disorders of the Pleura Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Bilothorax is the presence of bile in the pleural space and represents a rare cause of pleural effusion of extra vascular origin (PEEVO). Most reported cases are primarily right sided and due to pleurobiliary fistula resulting from biliary tract injury, direct spread of infection from the liver, or trauma to the hepatobiliary tree or diaphragm. We present a unique case of a large left-sided bilothorax occurring one month after laparoscopic gastric sleeve resection complicated by splenic hematoma and hemoperitoneum without evidence of pleurobiliary fistula. CASE PRESENTATION: A 52-year-old woman presented with dyspnea and left sided abdominal pain 1 month after laparoscopic sleeve gastrectomy complicated by hemoperitoneum and splenic hematoma. Computed tomographic (CT) imaging was obtained and revealed a moderate, complex left-sided pleural effusion without associated ascites and decrease in splenic hematoma. A thoracentesis was performed which evacuated 800 milliliters of brownish-green pleural fluid. Bacterial and fungal cultures were negative. The pleural fluid was exudative by Light’s Criteria (Table 1) and fluid bilirubin was 2.6 mg/dL, compared to a serum total bilirubin level of 0.9 mg/dL, confirming a diagnosis of bilothorax. Given the persistence of complex effusion following thoracentesis, a 14 french pigtail catheter was inserted with significant improvement in the residual effusion. Dedicated assessment of the CT imaging revealed no evidence of abnormal connection between the pleural space and biliary tree. Therefore, the bilothorax was likely due to breakdown of the splenic hematoma with resorption into the pleural space. This theory was supported by no additional reaccumulation over the next three days. The patient was discharged and remains without pleural effusion. DISCUSSION: Bilothorax is primarily seen as a complication of invasive biliary procedures and typically presents as biliary peritonitis with associated right-sided pleural effusion. We describe a case of left-sided bilothorax presenting with dyspnea and no signs of biliary peritonitis or pleurobiliary fistula one month after a laparoscopic gastric sleeve resection complicated by splenic hematoma. We posit that breakdown and subsequent resorption of the hematoma across the diaphragm into the pleural space was the primary cause of effusion. To our knowledge, this is the first case to describe such a mechanism in the formation of a bilothorax. CONCLUSIONS: A high index of clinical suspicion is necessary for diagnosis of this PEEVO due to resorption of splenic hematoma across the diaphragm. Delay in diagnosis of bilothorax can result in serious pleural complications such as the development of complex fibrinous septations and empyema. Our patient did well with drainage alone and required no further surgical intervention. Reference #1: Jenkinson MRJ, Campbell W, Taylor MA. Bilothorax as a rare sign of intra-abdominal bile leak in a patient without peritonitis. Ann R Coll Surg Engl. 2013;95(7):e12–e13. doi:10.1308/003588413X13629960047678 DISCLOSURES: No relevant relationships by Ankur Aneja, source=Web Response No relevant relationships by Matt Schimmel, source=Web Response No relevant relationships by Keriann Van Nostrand, source=Web Response

Anatomic landmarks for laparoscopic gastric sleeve resection in obese patients with type 2 diabetes mellitus

Background. The widespread use of laparoscopy has greatly accelerated the development of bariatric/metabolic surgery. Mastering of the laparoscopic techniques in bariatric surgery is important considering the potential complications and their implications for the patient’s life. Laparoscopic sleeve gastrectomy is a common bariatric/metabolic procedure worldwide. This procedure seems relatively standard, but some steps of this procedure still depends on the choice of the surgeon. There are two main steps that are not standardized yet — the choice of the calibration bougie and the distance from the pylorus to the first staple. The objective of the study is to establish the anatomical landmarks of the beginning of staplerfiring, which are simple, constant, and which can be used to standardize laparoscopic gastric sleeve resection. Materials and methods. Thirty-six obese patients with type 2 diabetes mellitus undergo laparoscopic sleeve gastrectomy. Body measurements, such an age, gender, height, weight, body mass index, and carbohydrate metabolism parameters, such as glucose, glycated hemoglobin, insulin, C-peptide, HOMA index was analyzed. The distance from the gastric pylorus was measured intraoperatively using a silicone tape. Results and discussion. The study included 19 women and 17 men, with an average age of 50.3 ± 9.6 years (range 30—67 years). The average body mass index is 50.6 ± 10.9 kg/m2 (range 30.2—82.3 kg/m2). The average distance from the pylorus to the first branch of the gastroepiploic artery, which runs in the transverse direction to the axis of the antrum, was 41 ± 1.7 mm (range 38—44 mm). The average distance for women was 40.6 ± 1.6 mm, for men — 41.5 ± 1.6 mm. Conclusion. The first branch of the gastroepiploic artery which runs perpendicularly to the axis of the antrum can be used as constant anatomical landmark. It is located on average 41 mm proximal to the gastric pylorus. Using this landmark for the first stapler firing allows to offset the need of formally measurements of the distance from stomach pylorus.

Efficacy of ultrasound-guided transversus abdominis plane (TAP) block for postoperative analgesia in laparoscopic gastric sleeve resection: a randomized single blinded case control study.

Pain following bariatric surgery can be quite troublesome and prolongs recovery. Transversus abdominis plane (TAP) block is a new regional anesthetic technique to reduce postoperative pain and is an important part of current analgesic regimen for many abdominal surgeries. The primary objective of our study was to assess the efficacy of the TAP block in controlling postoperative pain in laparoscopic sleeve gastrectomy. Secondary outcomes assessed in this study were postoperative nausea and vomiting (PONV), time to ambulate, readiness for discharge, and whether it leads to improved patient satisfaction. This is a prospective single blind randomized controlled study. A total of 60 patients were included in the study. Patients were allocated in two groups, using a computer generated randomization sequence using http://www.randomization.com . Test group included 30 patients who received Ultrasound-guided transversus abdominis plane (USG-TAP) block along with systemic analgesia and the Control group included 30 patients who received only systemic analgesia. Postoperatively patients were evaluated for pain and satisfaction using VAS scores and 'Capuzzo' satisfaction score, respectively. Sixty patients were enrolled in the study after fulfilling the eligibility criteria. No patient was lost to follow-up. The difference of VAS scores between test (TAP) and control (Non-TAP) was statistically significant both at rest and on movement. The patient satisfaction score in TAP group was higher than the control group (p value < 0.001). The patients who received TAP block showed earlier readiness for discharge, early ambulation, early resumption of bowel activity, and decreased incidence of PONV as compared to the non-TAP group. USG-guided TAP block is a feasible, minimally invasive technique and can be a part of an effective multimodal analgesia in morbidly obese patients undergoing bariatric surgery. Limitations of this study would be the small sample size and the study being Single-blinded.

Long-term results of laparoscopic gastric sleeve resection due to morbid obesity and metabolic syndrome

Introduction. The aim of this paper was to presents long-term results of a laparoscopic gastric sleeve resection in a ?super super? obese patient and a follow-up period of eight years. Case Outline. A patient with Body Mass Index (BMI) of 70 kg/m2 and Stage 3 obesity according to ?King?s Obesity Staging Criteria? (KOSC), with metabolic syndrome and cardiovascular risk of over 20%, and a pronounced severe obstructive sleep apnea, underwent a laparoscopic gastric sleeve resection (LGS). After two years, the patient reached BMI of 28.4 kg/m2 and eight years after the surgery has BMI of 34.3 kg/m2, and %EBMIL (% Excess BMI Loss) of 79.3%. According to the KOCS, he falls under Stage 0. Conclusion. LGS resection may be performed as a stand-alone procedure in ?super super? obese patients, with excellent long-term results.

Long-term results of laparoscopic gastric sleeve resection due to morbid obesity and metabolic syndrome

Introduction. The aim of this paper was to presents long-term results of a laparoscopic gastric sleeve resection in a “super super” obese patient and a follow-up period of eight years. Case Outline. A patient with Body Mass Index (BMI) of 70 kg/m2 and Stage 3 obesity according to “King’s Obesity Staging Criteria” (KOSC), with metabolic syndrome and cardiovascular risk of over 20%, and a pronounced severe obstructive sleep apnea, underwent a laparoscopic gastric sleeve resection (LGS). After two years, the patient reached BMI of 28.4 kg/m2 and eight years after the surgery has BMI of 34.3 kg/m2, and %EBMIL (% Excess BMI Loss) of 79.3%. According to the KOCS, he falls under Stage 0. Conclusion. LGS resection may be performed as a stand-alone procedure in “super super” obese patients, with excellent long-term results.

Our metabolic surgical activity, 2010-2016

The prevalence of morbid obesity and its co-morbidities - first of all diabetes type 2 - increased dramatically in the last decades. As the conservative ways of treatment (diet, training, etc.) in most cases does not lead to effective and long term weight loss, there is an increasing need for the metabolic surgical interventions. During the last 6 and half years 514 laparoscopic RouxY gastric bypass (LRYGB) and 54 laparoscopic gastric sleeve resection (LGSR) were performed in our department. The data of random selected 40 patients after primary LRYGB and 15 patients after sleeve resection were collected. The applied criteria of the indication for surgery, the routine examinations and treatments before and after the intervention, the results and the type and the rate of the complications will be presented. According to our experience both procedures are long term effective for weight loss and for the resolution of co-morbidities, and can be performed with low risk of complications. After LRYGB more effective weight loss (extra weight loss 88% vs. 68%) and higher rate of resolution of diabetes type 2, hypertension and gastro-esophageal reflux were found compared to sleeve resection. Based on our results we prefer LRYGB. Gastric sleeve resection is indicated by us, when there is no way - or only with high risk - to perform gastric bypass, taking into consideration of course the individual requirements of the patients.

Bariatric Surgery in University Clinic Center Tuzla - Results After 30 Operations.

Introduction:Project of Bariatric surgery in University clinic center (UCC) Tuzla has been initiated in 2009 as an idea of professor Dešo Mešić and soon after that Bariatric surgical team led by doctor Fuad Pasic has been created.Material and methods:Practical team education was realized in Croatia in hospital „Sisters of Mercy” under supervision of professor Miroslav-Bekavac Beslin. First bariatric operations in UCC Tuzla has been done in 2011 and it was biliopancreatic diversion (BPD) Scopinaro.Results and discussion:So far there has been done 30 operations and among them there have been used almost all operative modalities - restrictive, malabsorptive and combined (laparoscopic gastric banding-LAPGB, Roux-y mini gastric bypass, open and laparoscopic gastric sleeve resection, and over mentioned Scopinaro’s BPD). Beginning results are very promising according to the fact that almost all operated patients after one year stopped using antihypertensive, antidiabetic and antidepressant therapy, that average year’s weight loss is 35-100 kilograms and total satisfactions of patients after surgeries is obvious.

Comparison of recovery criteria in morbidly obese patients undergoing laparoscopic gastric sleeve resection following use of sevoflurane and isoflurane.

Context:The favorable kinetic properties of sevoflurane could be advantageous in obese patients undergoing bariatric surgery, improving recovery from general anesthesia (GA).Aims:To compare the recovery criteria following anesthesia with sevoflurane and isoflurane in morbidly obese patients undergoing laparoscopic gastric sleeve resection.Settings and Design:This was a prospective randomized controlled study conducted in 50 patients undergoing laparoscopic sleeve gastrectomy.Materials and Methods:Following awake fiberoptic intubation, GA was induced and maintained with sevoflurane in Group A and isoflurane in Group B. 2% sevoflurane and 1.2% isoflurane were used and concentration varied to maintain a mean arterial pressure (MAP) of >75 mm of Hg, maximum concentration being 3% for sevoflurane and 2% for isoflurane. Inhalational agent was terminated at time of skin suturing and patients were extubated when completely awake. Recovery criteria followed were eye opening on call, voluntary head raising on command for 5 s and orientation assessed by answering name and location.Statistical Analysis Used:Student's t-test was used to test statistical significance of difference in mean values between the groups, analysis of covariance was used to test diastolic blood pressure (DBP) changes and Chi-square test to assess association between categorical variables.Results:There was no significant variability in heart rate, systolic blood pressure, DBP and MAP between 2 groups up to 210 min. Group A patients had significantly faster eye opening compared to Group B (4.4 ± 1.6 vs. 9.2 ± 2.18 min), were significantly faster in obeying commands (6.08 ± 1.6 vs. 10.08 ± 2.02 min), had a significantly shorter extubation time (7.08 ± 1.6 vs. 11.16 ± 2.18 min) and significantly faster orientation in time as compared to Group B (9.24 ± 1.7 vs. 12.32 ± 2.42 min).Conclusion:Sevoflurane has a better recovery profile based on eye opening, obeying commands, time for extubation and orientation, than isoflurane in morbidly obese patients undergoing laparoscopic sleeve gastrectomy.

Quality of Life Parameters, Weight Change and Improvement of Co-morbidities After Laparoscopic Roux Y Gastric Bypass and Laparoscopic Gastric Sleeve Resection—Comparative Study

The laparoscopic Roux Y gastric bypass (LRYGB) and the laparoscopic gastric sleeve resection are frequently used methods for the treatment of morbid obesity. Quality of life, weight loss and improvement of the co-morbidities were examined. Match pair analysis of the prospectively collected database of the 47 gastric bypass and 47 gastric sleeve resection patients operated on in our hospital was performed. The quality of life parameters were measured with two standard questionnaires (SF 36 and Moorehead-Ardelt II). The mean preoperative and postoperative BMI was in gastric bypass group 46.1 and 28.1kg/m(2) (mean follow-up: 15.7months) and in gastric sleeve group 50.3 and 33.5kg/m(2) (mean follow-up: 38.3months). The SF 36 questionnaire yielded a mean total score of 671 for the bypass and 611 for the sleeve resection patients (p = 0.06). The Moorehead-Ardelt II test signed a total score of 2.09 for gastric bypass versus 1.70 for gastric sleeve patients (p = 0.13). Ninety percent of the diabetes was resolved in the bypass and 55% in the sleeve resection group. Seventy-three percent of the hypertension patients needed no more antihypertensive treatment after gastric bypass and 30% after sleeve resection. Ninety-two percent of the gastro-oesophageal reflux were resolved in the bypass group and 25% in the sleeve (with 33% progression) group. Ninety-four percent of the patients were satisfied with the result after gastric bypass and 90% after sleeve resection. The patients have scored a high level of satisfaction in both study groups. The gastric bypass is associated with a trend toward a better quality of life without reaching statistical significance, pronounced loss of weight and more remarkable positive effects on the co-morbidities comparing with the gastric sleeve resection.

Laparoscopic Sleeve Resection of a Recurrent Gastric Cascade: A Case Report

The cascade stomach consists of a biloculation of the gastric cavity into a ventral (corpus and antrum) and a dorsal (fundus) recess and is a rare cause of upper abdominal symptoms. The causes of gastric cascade described in the literature are manifold and are separated into congenital, functional, or organic disorders. Patients with a gastric cascade can have a range of upper abdominal symptoms, including nausea, vomiting, dyspepsia, eructation, heartburn, epigastric pain, and early satiety. This disorder is often difficult to diagnose or is not recognized and, therefore, its true incidence is currently not known. As a consequence, data on the treatment of the condition are limited. Suggested treatment options in the literature range from conservative measures, such as bending exercises or dietary adjustments, to operative corrections, such as gastropexy and laparoscopic gastro-gastric anastomosis. In this paper, we summarize the literature findings on gastric cascade and report on a new treatment option: the laparoscopic gastric sleeve resection.

Laparoscopic Gastric Re-Banding versus Laparoscopic Gastric Bypass as a Rescue Operation for Patients with Pouch dilatation

The authors assessed whether laparoscopic rebanding or laparoscopic Roux-en-Y gastric bypass (LRYGBP) is the best approach for failed gastric banding after pouch dilatation. Between January 2000 and June 2005, 489 patients underwent laparoscopic gastric banding, and of these, 33 (6.7%) required rescue procedures for pouch dilatation. Each reoperated patient was contacted to obtain information about their postoperative course. Additionally, preoperative weight and BMI, weight loss at 1 year postoperatively, weight at time of pouch dilatation and the time-period between the primary operation and pouch dilatation were analyzed. The most common operation for pouch dilatation was band repositioning or rebanding (16 patients). Band removal without replacement was performed in 7 patients. 8 patients underwent conversion to a LRYGBP. 1 patient underwent laparoscopic gastric sleeve resection and 1 patient received an intragastric balloon. Patients who underwent conversion to LRYGBP are very content and, although weight loss has been nearly the same as after gastric banding, they would prefer the gastric bypass operation to the gastric banding. Conversion to LRYGBP appears to offer significant advantages, and appears to be the rescue therapy of choice after failed laparoscopic gastric banding.

Laparoscopic Reoperative Sleeve Gastrectomy for Poor Weight Loss after Biliopancreatic Diversion with Duodenal Switch

The revisional surgery for patients with inadequate weight loss after biliopancreatic diversion with duodenal switch (BPD/DS) is controversial. It has not yet been determined whether a common channel should be shortened or gastric pouch volume reduced. Since the revision of the distal anastomosis remains technically difficult and associated with possible complications, we turned our attention to the reduction of gastric sleeve volume. This operation is more feasible and potential complications are less probable. We present the case of a 47-year-old women with a life-long history of morbid obesity. She was operated on in January 2000 with a laparoscopic BPD/DS with 100 ml gastric pouch, 150 cm of alimentary limb and 100 cm of common channel. Before this operation, her weight was 170 kg, with BMI 64 kg/m(2). She lost most of her excess weight within 17 months after surgery and was regaining weight at 77 kg and BMI 29 kg/m(2). Upper GI series showed a markedly dilated gastric pouch. Her second surgery consisted of a laparoscopic sleeve partial gastrectomy along the greater curvature using endo GIA staplers with bovine pericardium for reinforcement of the stapler line. No postoperative complications occurred. The patient was discharged on the first postoperative day. Significant further weight reduction was noted, and at 10 months after surgery, her weight is 61 kg with BMI 22. A repeat laparoscopic gastric sleeve resection was performed for inadequate weight loss after BPD/DS, and resulted in further weight reduction.