Sleeve Gastrectomy For Morbid Obesity Research Articles

Laparoscopic sleeve gastrectomy for morbid obesity: role of intraluminal and intraperitoneal postoperative drainage.

Bleeding and staple line leak are the most common postoperative complications of LSG. To prevent and/or to promptly identify such complications, conventional peri-operative protocols imply post-operative gastric decompression (NGT) and staple line drain (IAD). Our aim was to evaluate the role of naso-gastric tube (NGT) and intra-abdominal drain (IAD) in preventing and/or facilitating identification and treatment of post-operative complications after sleeve gastrectomy. A retrospective observational study on two consecutive series has been undertaken to evaluate the real utility of routine placement of NGT and IAD at the end of a LSG to prevent (primary end-point), promptly identify (secondary end-point) and manage (tertiary end-point) bleeding and staple line leakage. Collected outcome data of all consecutive cases, which underwent primary LSG at our Department, were analyzed. The first 100 consecutive patients (group A) received the standard perioperative protocol and the other consecutive 100 (group B) received a fast track protocol (no NGT neither IAD). The two groups were not different in their outcome. Two bleeding occurred in Group A and were conservatively treated. One abscess developed in group B soon after surgery. It was diagnosed by an abdominal CT performed because patients presented fever, leucocitosis and tachycardia. It was successfully treated by percutaneous ultrasound-guided drainage. One fistula occurred in group B after discharge on 30th post-operative day. Fistula was suspected based on fever and tachycardia in absence of any abdominal discomfort and was confirmed by an abdominal CT. The patient was successfully treated in 40 days by endoscopic positioning of a gastric tube-prosthesis and percutaneous ultrasound-guided drainage of abdominal collection. A third patient in group B experienced bleeding suspected due to hemoglobin drop and confirmed by abdominal CT. He also was conservatively treated. In conclusion, placement of drains does not facilitate detection of leak, abscess, or bleeding after primary LSG.

Five-year results of laparoscopic sleeve gastrectomy for the treatment of severe obesity

Since 2011, the most used bariatric technique in France has been the sleeve gastrectomy. There are still few studies exploring the medium and long-term results of this technique. To describe medium-long-term (5years) results of a cohort of CHU Montpellier experience in sleeve gastrectomy for morbid obesity. All patients that underwent laparoscopic sleeve gastrectomy (LSG) from January 2005 to June 2013 were included in this study. A total of 1050 patients were operated. 72.86% were women. The mean preoperative BMI was 44.58kg/m2 (±7.71). A total of 183 patients (18.5%) were super-obese (BMI>50kg/m2). LSG was proposed as primary procedure, and also after failure of adjustable gastric banding in 169 patients (16.9%) or after vertical banded gastroplasty in 7 cases (0.7%). There were 38 postoperative gastric fistulas (3.8%) and 3 of them required some kind of bypass to be definitively treated. There were also 34 hemorrhages (3.4%) of which 21 were reoperated for hemostasis. Two gastric stenoses at the angulus (0.2%) were managed with dilation or RYGB. Overall reoperative rate was 6.8%. One patient died of pulmonary embolism. Most common late complication was GERD (39.1%). After 3, 4 and 5years of LSG, the average of %EBL was, respectively, 75.95% (±29.16) (382 patients), 73.23% (±31.08) (222 patients) and 69.26% (±30.86) (144 patients). The success rate at 5years was 65.97% (95 patients). The improvement or remission of comorbidities was found, respectively, in 88.4 and 57.2% of diabetic patients; 76.9 and 19.2% for hypertensive patients and 98 and 85% for patients with sleep apnea syndrome. LSG is a bariatric surgery technique that presents a very good risk/benefit ratio. Five-year results are very convincing. GERD is the main long-term complication.

Impact of preoperative body mass index on the final outcome after laparoscopic sleeve gastrectomy for morbid obesity.

Laparoscopic sleeve gastrectomy (LSG) is a popular bariatric surgery due to its excellent results and limited morbidity. Our study aims to assess the efficacy of LSG in terms of loss of weight and co-morbidity improvement and to evaluate the impact of preoperative body mass index (BMI) on the final outcome. The data of 173 patients who underwent LSG were analyzed. Laparoscopic sleeve gastrectomy was indicated only for patients with BMI >40. Mean postoperative BMI, co-morbidity improvement, operative data and complications, length of hospital stay and excess weight loss were evaluated and recorded. This study included 151 females and 22 males with a mean age of 37.6 years. Patients were divided into two groups according to their BMI (group I <50, group II >50). Mean preoperative BMI was 53.8 kg/m2. Mean operative time was 120 minutes. Mean duration of hospital stay was 3.2 days. Mean postoperative BMI decreased to 47.3 kg/m2 at 1 year. Excess weight loss was 43.1% at 6 months, 71.1% at 1 year, and 87.5% at 5 years. Group I showed a significantly shorter length of hospital stay, more improvement of laboratory parameters and more reduction in BMI as compared to group II. There was one mortality and six cases had gastric staple line leakage. Laparoscopic sleeve gastrectomy is an efficient treatment to achieve significant weight loss that is maintained up to 5 years of follow up, also it improves some of the obesity related co-morbidities. This beneficial impact of LSG appears to be significantly higher in patients with BMI <50.

Midterm Clinical Outcomes of Antrum Resection Margin at Laparoscopic Sleeve Gastrectomy for Morbid Obesity.

Laparoscopic sleeve gastrectomy (LSG) is one of the most frequently performed procedures in obesity surgery. The benefits of minimally invasive surgery include rapid recovery. We evaluated the clinical outcomes of different resection margin lengths from the pylorus in LSG. This retrospective study included 152 patients who underwent LSG from January 2011 to October 2014. The antrum was resected 2cm from the pylorus in 84 patients (group A) and 6cm from the pylorus in 68 patients (group B). The patients' demographics, staple line distance, complications, sex, age, body mass index loss, length of hospital stay, and comorbidities were retrospectively reviewed. The patients comprised 104 women (68.4%) and 48 men (32.6%) with a mean age of 41.2years (range, 28-53years). The percent total and excess weight loss were statistically significant in both groups at 6 and 12months postoperatively. Weight loss was significantly greater in group A than that in B at 6 and 12months, but the difference at 24months was not statistically significant. The results of pH monitoring showed significantly lower scores in group A than those in B at 6 and 12months, but no difference at 24months. LSG is an effective procedure with good short-term outcomes. Both procedures described herein are equally effective with respect to the patient's return to daily activities. Increasing the distance from the resection line to the pylorus is associated with better weight loss but slightly increased symptoms of gastroesophageal reflux disease without a significant difference in complications.

Long-Term Results of Laparoscopic Sleeve Gastrectomy for Morbid Obesity: 5 to 8-Year Results.

Although long-term results of sleeve gastrectomy (LSG) remain scarce in the literature, its popularity as a stand-alone procedure has accounted for a global increase in LSG performance. In this retrospective study, the authors present 5 to 8-year follow-up results in terms of weight loss, failure/revision rate, and comorbidity resolution from a single center. A prospectively maintained database was reviewed for patients who underwent LSG between 2007 and 2010. Data analysis on weight loss, comorbid conditions, revision surgery, and mortality was conducted. Median percentage excess BMI loss (%EBMIL) was 59.0, and 53.9%, and median percentage total weight loss (%TWL) was 25.1, and 22.9% at 5 and 8years, respectively. Revision to gastric bypass due to insufficient weight loss or gastroesophageal reflux disease (GERD) was performed in 42 patients (15.2%). Resolution of comorbid condition was achieved in 91% of patients with obstructive sleep apnea syndrome (OSAS), 68% of patients with type 2 diabetes (T2DM), 53% of patients with hypertension, and 25% of patients with dyslipedemia. Loss to follow-up rate was 45% at 5years, 28% at 6years, 23% at 7years, and 13% at 8years. This study adds to the currently available data confirming the LSG to be a safe and effective procedure at long term. Data from high-volume studies are needed to establish the definite role of the LSG in the spectrum of bariatric procedures.

Laparoscopic Sleeve Gastrectomy for Morbid Obesity in 3003 Patients: Results at a High-Volume Bariatric Center.

Laparoscopic sleeve gastrectomy (LSG) is gaining wide acceptance as a single surgical treatment for obesity. The reported morbidity and mortality rates are low. We herein report the results of LSG performed in a high-volume center by an experienced team. Retrospective analysis of a prospectively maintained database of all bariatric surgery (BS) was performed between May 2006 and December 2014. Data inspected included operative time, length of hospital stay (LOS), comorbidity resolution, re-operation, percent excess weight loss (%EWL), and 30-day morbidity and mortality. In the study period, 3003 patients underwent BS (1901 (63%) female). Mean age and body mass index (BMI) were 43years (range 14-73) and 42.8kg/m(2) (range 35-73), respectively. %EWL at 1year was 72% (n = 937; 57% follow-up rate). There was 1 perioperative mortality due to bleeding (0.03%). Comorbidity improvement and resolution were 98% for obstructive sleep apnea, 79% for diabetes mellitus, 87% for dyslipidemia, and 85% for hypertension. Mean operative time and LOS were 50min (range 32-94) and 2.2days (range 1-38), respectively. Of the patients, 132 had complications (4.4%), 25 leaks (0.83%), 63 bleeding (2.1%), 1 intra-abdominal abscesses (0.03%), 3 sleeve strictures (0.1%), 2 mesenteric vein thromboses (0.06%), 10 trocar site hernias (0.3%), and 78 symptomatic cholelithiasis (2.6%). Re-operation was needed in 13 patients (0.43%). In a high-volume center with an experienced team, LSG can be performed with low morbidity and mortality.

Management of gastric leaks after laparoscopic sleeve gastrectomy for morbid obesity: A tertiary care experience and design of a management algorithm.

BACKGROUND:Laparoscopic sleeve gastrectomy (LSG) is the most commonly performed ‘standalone’ bariatric procedure in India. Staple line gastric leaks occur infrequently but cause significant and prolonged morbidity. The aim of this retrospective study was to analyse the management of patients with a gastric leak after LSG for morbid obesity at our institution.PATIENTS AND METHODS:From February 2008 to 2014, 650 patients with different degrees of morbid obesity underwent LSG. Among these, all those diagnosed with a gastric leak were included in the study. Patients referred to our institution with gastric leak after LSG were also included. The time of presentation, site of leak, investigations performed, treatment given and time of closure of all leaks were analysed.RESULTS:Among the 650 patients who underwent LSG, 3 (0.46%) developed a gastric leak. Two patients were referred after LSG was performed at another institution. The mean age was 45.60 ± 15.43 years. Mean body mass index (BMI) was 44.79 ± 5.35. Gastric leak was diagnosed 24 h to 7 months after surgery. One was early, two were intermediate and two were late leaks. Two were type I and three were type II gastric leaks. Endoscopic oesophageal stenting was used variably before or after re-surgery. Re-surgery was performed in all and included stapled fistula excision (re-sleeve), suture repair only or with conversion to roux-en-Y gastric bypass or fistula jujenostomy. There was no mortality.CONCLUSION:Leakage closure time may be shorter with intervention than expectant management. Sequence and choice of endoscopic oesophageal stenting and/or surgical re-intervention should be individualized according to clinical presentation.

Laparoscopic sleeve gastrectomy for morbid obesity: does the size of the bougie matter?

Background Laparoscopic sleeve gastrectomy (LSG) is a safe and effective surgical treatment modality for morbid obesity. Variations in surgical technique could affect the results. The optimal size of the bougie remains controversial. The aim of this study was to evaluate the first-year outcome of LSG using two different sizes of bougies. Patients and methods Between March 2011 and January 2014, 102 morbidly obese patients underwent LSG. These patients were divided into two groups: group 1 (50 patients) and group 2 (52 patients). In group 1, 32-Fr bougies (orogastric calibration tube) were used, and in group 2 40-Fr bougies were used. Patients completed at least 6 months of follow-up visits. Results The excess body weight loss percentage in group 1 was 53.6 ± 10.96% at 6 months and 69.4 ± 15.6% at 1 year postoperatively, whereas in group 2 it was 52.7 ± 11.27% at 6 months and 66.4 ± 13.4% at 1 year postoperatively, with no statistically significant difference between the two groups. There were neither intraoperative complications nor postoperative mortalities. The overall complication rate was 14.7% (15 patients) with no statistically significant difference between the two groups (14% in group 1 vs. 15.4% in group 2). The postoperative hospital stay was 2.3 days in group 1 versus 2.2 days in group 2. There was 58.8% complete resolution of diabetes mellitus, 60% resolution of hypertension, and 87.5% resolution of sleep apnea 6 months after sleeve gastrectomy with no statistically significant difference between the two groups. Conclusion LSG is a safe and effective treatment method for morbid obesity. Bougie size does not affect the short-term outcomes.

Robotic sleeve gastrectomy for morbid obesity: report of a 5 year experience.

Robotic bariatric procedures are nowadays in the surgeon's arsenal for the treatment of morbid obesity. With proven efficacy and advantages in gastric bypass procedures, we attempted to employ robotics and study the results in the other major bariatric procedure, sleeve gastrectomy. We used the da Vinci S® system to perform 19 robotic sleeve gastrectomies (RSGs) and reviewed the 5-year results as far as excess body weight loss is concerned, and amelioration of obesity-related comorbidities. Mean percentage of excess body weight loss (%EWL) was 64.4%, 67.1%, 61.7%, 63.1%, 64.8% for the first, second, third, fourth and fifth year, respectively. Neither of our two patients with diabetes mellitus (0%) or hypertension (0%) showed remission, while all six of our patients (100%) showed remission of their sleep apnoea after 5 years. Robotic sleeve gastrectomy is an effective procedure as far as initial excess weight loss is concerned and this loss is well maintained 5 years post-operatively, a finding similar to relevant data after conventional laparoscopic sleeve gastrectomy. Copyright © 2015 John Wiley & Sons, Ltd.

155 Prospective study of the effect of laparoscopic sleeve gastrectomy for morbid obesity on overactive bladder symptoms

155 Prospective study of the effect of laparoscopic sleeve gastrectomy for morbid obesity on overactive bladder symptoms

Gastroesophageal Reflux Symptoms After Laparoscopic Sleeve Gastrectomy for Morbid Obesity. The Importance of Preoperative Evaluation and Selection.

Background:Gastroesophageal reflux disease (GERD) is prevalent in morbidly obese patients, and its severity appears to correlate with body mass index (BMI).Aim:The aim of this study is to investigate the status of GERD after laparoscopic sleeve gastrectomy (LSG).Materials and Methods:A prospectively maintained database of all the patients who underwent LSG from February 2008 to May 2011 was reviewed.Results:A total of 131 patients were included. The mean age and the BMI of the patients were 49.4 years and 48.9 kg/m2, respectively. Prior to LSG, subjective reflux symptoms were reported in 67 (51%) patients. Anatomical presence of hiatal hernia was endoscopically confirmed in 35 (52%) patients who reported reflux symptoms prior to LSG. All these patients underwent simultaneous hiatal hernia repair during their LSG. The overall mean operative time was 106 min (range: 48-212 min). There were no intra- and 30-day postoperative complications. Out of the 67 preoperative reflux patients, 32 (47.7%) reported resolution of their symptoms after the operation, 20 (29.9%) reported clinical improvement, and 12 (22.2%) reported unchanged or persistent symptoms. Three patients developed new-onset reflux symptoms, which were easily controlled with proton pump inhibitors. No patient required conversion to gastric bypass or duodenal switch because of the severe reflux symptoms. At 18 months, the follow-up data were available in 60% of the total patients.Conclusion:LSG results in resolution or improvement of the reflux symptoms in a large number of patients. Proper patient selection, complete preoperative evaluation to identify the presence of hiatal hernia, and good surgical techniques are the keys to achieve optimal outcomes.

Single-port sleeve gastrectomy, a valuable procedure in the treatment of morbidly obese patients

Background Laparoscopic sleeve gastrectomy has recently been proposed as a sole bariatric procedure because of the considerable weight loss that is achieved in morbidly obese patients. Single-incision laparoscopic sleeve gastrectomy has recently gained acceptance in bariatric surgery as the procedure has possible benefits. The aim of our study was to evaluate the feasibility and safety of a laparoscopic single-incision sleeve gastrectomy for morbid obesity. Patients and methods From January 2011 to March 2014, single-port laparoscopic sleeve gastrectomy through a special single-port silicon device that is flexible and reusable with a novel method for liver retraction was performed on 30 consecutive morbidly obese patients enrolled from Ain Shams University hospitals. The patients were 22 women (73.3%) and eight men (26.7%), mean age 31 years (range: 23-45) years. The patients recruited in this study had a mean BMI of 41.3 kg/m 2 (range: 35-45) kg/m 2 . The operative technique, operative time, postoperative hospital stay, and early and late postoperative complications were monitored, and the percentage of excess weight loss (%EWL), which was measured at 3, 6, and 12 months, respectively, was determined. Results A total of 30 single-incision laparoscopic sleeve gastrectomies were performed. The procedure was performed successfully in 27 patients (90%), with three conversions (10%) to traditional laparoscopic sleeve gastrectomy. The mean operative time was 92 min (range: 80-135) min, whereas the mean hospital stay was 2.4 days (range: 2-4) days. In terms of morbidities, there were six cases of vomiting (20%), one case of wound infection (3.3%), and two cases of incisional hernia (6.6%). The %EWL was 26, 38.3, and 61.43 at 3, 6, and 12 months, respectively. There were no mortalities in our study. Conclusion Laparoscopic single-incision sleeve gastrectomy seems to be safe, technically feasible, and reproducible. Our technique for liver retraction provides adequate exposure. However, additional work must be carried out before these techniques achieve the level of standardization. More flexible articulating instruments, high-illumination, high-magnification, flexible endoscopes, and free-standing insertable retractors need to be developed.

Laparoscopic Sleeve Gastrectomy for Morbid Obesity with Intra-operative Endoscopy: Lessons We Learned After 100 Consecutive Patients.

Sleeve gastrectomy has become the second most common bariatric operation due to its low rates of morbidity and mortality, satisfactory treatment of patients' obesity, and resolution of associated co-morbidities. According to standard technique, calibration of the stomach is performed with varying sizes of bougies while use of intra-operative endoscopy has only sparsely been reported. Between 2004 and 2013, 100 patients have undergone laparoscopic or robotic sleeve gastrectomy with intra-operative endoscopic guidance. Technical aspects of the operation, results concerning morbidity, progressive weight loss, and resolution of co-morbidities were retrospectively reviewed. Morbidity and mortality was zero. Rates of excess weight loss at 6 months and 1 and 3 years were 52.1, 67.4, and 61.3 %, respectively. Patients' highest rate of excess weight loss was achieved 18 months post-operatively. These rates were inversely related with preoperative age, body mass index, and the existence of preoperative co-morbidities. Sleeve gastrectomy with intra-operative endoscopic guidance is at least as safe and effective as with the bougie. Given the available expertise and equipment, the use of this technique can increase the intra-operative sense of safety with no compromise or even improvement of the immediate or long-term results.

Evolving endoscopic management options for symptomatic stenosis post-laparoscopic sleeve gastrectomy for morbid obesity: experience at a large bariatric surgery unit in New Zealand.

Symptomatic stenosis is an increasingly recognised complication following laparoscopic sleeve gastrectomy (LSG) to treat obesity with a reported prevalence between 0.1 and 3.9 %. This study aimed to determine the prevalence and management options for symptomatic stenosis (SS) after LSG. A total of 857 patients underwent LSG at Counties Health Auckland New Zealand between May 2008 and June 2013. All cases referred for management of symptomatic stenosis after LSG were recorded. Symptomatic stenosis developed in 26 (3.03 %) out of 857 receiving LSG confirmed by barium swallow. Three of these 26 patients developed a fixed stenosis in the proximal stomach. These were all successfully treated by one dilatation of controlled radial expansion (CRE) balloon of <20 mm. Of the 23 patients that showed a fixed stenosis at the incisura angularis, 16 were initially treated with dilatation by a CRE balloon. Seven of these patients were successfully dilated although one needed two dilatations. Of the nine failures, six were successfully treated using a 30-mm achalasia balloon dilator and the other three required temporary placement of a self-expandable metal stent (SEMS). Based on this experience, seven other patients who presented with strictures at the incisura >3 cm long were initially treated with the achalasia balloon. Five were successfully dilated, but two required temporary placement of a SEMS. None of the 26 patients required a surgical procedure to correct their stenosis. The use of a 30-mm achalasia balloon and a SEMS is an effective and safe treatment for patients with SS post-LSG who do not respond to dilatation. Achalasia balloon could be the first-line treatment in selected cases.

Laparoscopic sleeve gastrectomy for morbid obesity: 5-year results

BackgroundData concerning the long-term efficacy of laparoscopic sleeve gastrectomy in the treatment of morbid obesity remain scarce. In this retrospective, the authors present 5-year follow-up of 30 patients having undergone laparoscopic sleeve gastrectomy. MethodsSince 2004, 30 patients underwent laparoscopic sleeve gastrectomy and completed 5 years of follow-up. Five patients were subsequently subjected to laparoscopic Roux-en-Y gastric bypass and were excluded from further analysis. The remaining 25 patients comprised the study population. ResultsMean excess weight loss was 65.2 ± 6.1%, 64.7 ± 5.6%, 62 ± 4.9%, 58.2 ± 5.5%, and 56.4 ± 5.8% for the first 5 years, respectively. There were no deaths, nor any major morbidity. Remission of comorbidities was observed in 40% to 80.9% of cases. ConclusionsLaparoscopic sleeve gastrectomy is a safe and effective means of treatment of morbid obesity both in the short and in the long term. More research is needed to better predict which patient will benefit most from this operation.

Does helicobacter pylori infection have influence on outcome of laparoscopic sleeve gastrectomy for morbid obesity?

IntroductionAmong the surgical procedures for treatment of morbid obesity, laparoscopic sleeve gastrectomy has known widespread diffusion in the last years, although it is not free from significant morbidity rates. Aim of this work is to evaluate the incidence of Helicobacter pylori (HP) infection on the postoperative outcome of patients undergoing laparoscopic sleeve gastrectomy. MethodsBetween January 2008 and December 2013, 184 patients (65 males, 119 females), mean age 35.8 ± 5.7 years, affected with morbid obesity, mean BMI 46.6 ± 6.7, underwent laparoscopic sleeve gastrectomy. All the specimens at the end of the operation were analysed by the same pathologist. Histological grading was based on the Sidney classification. ResultsSeventy-two of the patients (39.1%) were HP positive, while 112 (60.9%) were negative. No significant differences were observed between the HP+ and HP− group in terms of age, sex, weight, BMI, incidence of comorbidities and duration of follow-up. All the operations were completed via laparoscopic approach. No mortality was observed. Postoperative complications occurred in 5 patients (2.7%): three leaks (1.6%), all in the HP- group and two bleedings (1.1%), one in the HP+ and one in the HP− group. In two cases a reintervention was necessary. No significant differences were observed in the morbidity rates between the two groups. Overall mean excess weight loss at 6 months, 12 months and 24 months was respectively 47.4 ± 11.3%, 61.1 ± 12.4% and 68.4 ± 13.5%, with no significant differences between the HP+ and HP− groups. ConclusionsHP infection seems not to influence postoperative outcome of patients operated of laparoscopic sleeve gastrectomy.

Short-term outcomes of sleeve gastrectomy for morbid obesity: does staple line reinforcement matter?

BackgroundStand-alone laparoscopic sleeve gastrectomy (LSG) has been found to be effective in producing weight loss but few large, one-center LSG series have been reported. Gastric leakage from the staple line is a life-threatening complication of LSG, but there is controversy about whether buttressing the staple line with a reinforcement material will reduce leaks. We describe a single-center, 518-patient series of LSG procedures in which a synthetic buttressing material (GORE® SEAMGUARD® Bioabsorbable Staple Line Reinforcement) was used in the most recently treated patients.MethodsWe retrospectively reviewed the medical records of all patients who underwent LSG in our unit between September 2007 and December 2011. Patients treated before August 2009 did not receive the staple line reinforcement material (n = 186), whereas all patients treated afterward did (n = 332).ResultsThe percentages of excess weight loss in the 518 patients (mean age, 41 years; 82 % female; mean preoperative body mass index, 44 kg/m2) were 67 % (79 % follow-up rate) at 6 months postoperatively, 81 % (64 %) at 1 year, and 84 % (30 %) at 2 years. Type 2 diabetes resolved in 71 % of patients (91/128). Patients given reinforcement material had baseline characteristics similar to those in the no-reinforcement-material group, but had no postoperative staple line leaks or bleeding. The no-reinforcement group had three leaks (p = 0.045) and one case of bleeding.ConclusionsLSG resulted in substantial short-term weight loss. Use of the bioabsorbable staple line reinforcement material may decrease leaks after LSG.

Are there risk factors that increase the rate of staple line leakage in patients undergoing primary sleeve gastrectomy for morbid obesity?

Laparoscopic sleeve gastrectomy (LSG) is currently being performed with increasing frequency worldwide. It offers an excellent weight loss and resolution of comorbidities in the short term with a very low incidence of complications. However, the ever present risk of a staple line leak is still a major concern. Since 2005, data from obese patients that undergo bariatric procedures in Germany are prospectively registered in an online database and analyzed at the Institute of Quality Assurance in Surgical Medicine. For the current analysis, all patients that had undergone primary sleeve gastrectomy for morbid obesity within a 7-year period were considered. Using the GBSR, data from 5.400 LSGs were considered for analysis. Staple line leak rate decreased during the study period from 6.5 to 1.4 %. Male gender, higher BMI, concomitant sleep apnea, conversion to laparotomy, longer operation time, use of both buttresses and oversewing, and the occurrence of intraoperative complications were associated with a significantly higher leakage rate. On multivariate analysis, operation time and year of procedure only had a significant impact on staple line leak rate. The results of the current study demonstrated that there are factors that increase the risk of a leakage which would enable surgeons to define risk groups, to more carefully select patients, and to offer a closer follow-up during the postoperative course with early recognition and adequate treatment. All future efforts should be focused on a further reduction of serious complications to make the LSG a widely accepted and safer procedure.

Impact of extent of antral resection on surgical outcomes of sleeve gastrectomy for morbid obesity (a prospective randomized study).

Laparoscopic sleeve gastrectomy (LSG) is a surgical technique that treats morbid obesity. Consecutive patients with morbid obesity treated by LSG at our department were evaluated. Patients enrolled in the study were randomized into group I (LSG begins the division 2 cm from the pylorus) and group II (LSG begins the division 6 cm from the pylorus). The primary outcome measure was the percent of excess weight loss (% EWL); secondary outcomes included postoperative morbidity and mortality and improvement of comorbidity. One hundred five patients (79 (75.2 %) were females) were randomized into two groups of (GI) 52 patients and (GII) 53 patients. In group I, the mean % EWL was 51.8 ± 13.9, 63.8 ± 16.1 and 71.8 ± 12; however, in group II, the mean % EWL was 38.3 ± 10.9, 51.9 ± 13.6 and 61 ± 11.1 at 6, 12, and 24 months, respectively (P = 0.0001, 0.0001, 0.003). There was weight regain after 2 years in five patients in group II and only one patient in group I (P = 0.09). There was no significant difference between both group as regards gastric leakage, vomiting or GER. There was significant improvement in comorbidity after LSG in both groups, but no significant difference between them. Hospital mortality occurred in group II in one case as a result of gastric leakage. LSG is a safe and effective procedure with good short-term outcome. Increasing the size of the resected antrum is associated with better weight loss without increasing the rate of complications significantly.

Morphology, Localization, and Patterns of Ghrelin-producing Cells in Stomachs of a Morbidly Obese Population

The role of the hormone ghrelin in the pathogenesis of morbid obesity is unclear. Researchers have identified its involvement in multifunctional activities that include appetite regulation, intestinal motility, release of growth hormone, and cell proliferation. The purpose of this study is to investigate and distinguish a pattern, if present, in ghrelin-producing cells and to record their distribution and quantity in a heterogenic morbidly obese population. The Bariatric & Metabolic Institute, Section of Minimally Invasive Surgery, Cleveland Clinic Florida, Weston, FL. Thirty-six patients who underwent sleeve gastrectomy for morbid obesity were evaluated for number and distribution of gastric ghrelin. Sections of fundus, body, and antrum were evaluated by using a ghrelin antibody staining technique. The gross specimens were divided into the following 3 zones: (1) fundus; (2) body; and (3) antrum. Three sections were then submitted from each zone. The ghrelin cells were counted using an image analyzer (MetaMorph; Universal Imaging Corporation, Downingtown, PA) after staining the blocks with antighrelin antibody. Counting ghrelin cells was standardized, and for each section 10 high-power fields were examined at ×4000. Our statistical analysis entailed a Student t test to compare the number of cells by age, sex, race, diabetic/nondiabetic, and body mass index. A P-value <0.05 was considered statistically significant. Thirty-six patients (female 20/male 16) were studied. The average age of these patients was 45.6 (18 to 71) years. Race distribution was as follows: whites, 50% (18); African American, 13.9% (5); and Hispanic, 36.1% (13). Patients with diabetes comprised 13.9% of the cohort (5). Average body mass index was 44.9 kg/m (31 to 70). Significant differences in ghrelin cell distribution were found when comparing gastric anatomy location. Ghrelin cells were significantly more abundant in the gastric fundus when compared with the body and the antrum. Quantities of cells in the antrum were significantly higher in the Hispanic population (P=0.0054). No significant differences among other groups were observed. In conclusion, ghrelin-producing cells seem to be more abundant in the fundus of morbidly obese patients. No significant differences were found in terms of number of cells by age, sex, presence of diabetes, or body mass index. There was an incidental finding of a higher concentration of these cells located in the antrum of the Hispanic population when compared with the white cohort.