Bariatric surgery Laparoscopic Sleeve Gastrectomy

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Bariatric surgeryLaparoscopic Sleeve Gastrectomy

• By
• Dr Hosam Ghazy El-Banna
• Assistant Professor of General surgery
• Mansoura Faculty of Medicine

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Introduction

• Laparoscopic Sleeve gastrectomy (LSG) is a new
  restrictive bariatric procedure increasingly
  indicated in the treatment of morbid obesity.
• LSG is a reproducible and seems to be an
  effective treatment to achieve significant weight
  loss after 12 months follow-up.

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Indications

• LSG was indicated for weight reduction only for
  patients with a BMI gt 40 or gt 35 kg/m2 with
  severe comorbidity.
• Patients assessed by a dietician, a nutritionist,
  and a psychologist before surgery.

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Preoperative preparation

• Start Atkins diet for 2 weeks before the surgery
  to reduce the fat around your liver.
• Make sure to be on a regular intake of clear
  fluids 48 hours before surgery.
• Stop any medication unless indicated and
  recommended by your doctor.

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Operative procedure

• Operations are performed under general anesthesia
  using the supine position.
• Each procedure required only 4 trocars.
• Two 12-mm ports were placed in the supraumbilical
  region and in the left upper quadrant.
• One 10-mm port was placed in the right upper
  quadrant for liver retraction.
• One 12-mm port used for stapling was placed in
  the left mid-abdomen, just medial to the
  mid-clavicular line .

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Placement of 4 trocars
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• Pneumoperitoneum was induced by primary trocar
  insertion and maintained at a pressure of 16 mm
  Hg.
• Dissection began on the greater curvature, 6 cm
  from the pylorus.
• The gastrocolic ligament along the greater
  curvature of the stomach was opened using a
  coagulator and was freed as far as the
  cardioesophageal junction.
• A 36-F plastic tube was then inserted perorally
  into the stomach by the anesthesiologist and was
  directed toward the pylorus.

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• A laparoscopic linear stapler was introduced into
  the peritoneal cavity and was positioned so that
  it divided the stomach parallel to the orogastric
  tube along the lesser curvature.
• The instrument was fired, reloaded, and the
  maneuver was repeated 60-mm green cartridge was
  used to staple the antrum followed by 3 or 4
  sequential 60-mm gold cartridges to staple the
  remaining gastric corpus and fundus.
• After 5 or 6 firings of the stapler, the greater
  curvature was completely detached from the
  stomach.

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• A methylene blue test was performed to exclude
  staple-line leakage.
• The gastric suture line was not systematically
  reinforced except in the case of bleeding or
  positive methylene blue test, in which case a
  drain was placed along the staple line.

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• A nasogastric tube was left in place.
• A water-soluble upper gastrointestinal (GI)
  contrast study was performed on the first
  postoperative day, and oral fluids were allowed
  if no leakage was demonstrated.
• Patients were discharged except in the case of a
  complication resulting in prolongation of the
  hospital stay.

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Follow up

• Patients were reviewed at 1 month and then every
  3 months.
• Mortality and morbidity were defined as death or
  complications and reoperations during the first
  30 days after the operation or during the
  hospital stay, respectively.

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Eating after surgery

• Immediately after surgery, the patient is
  restricted to a clear liquid diet.
• The next stage provides a blended or pureed
  sugar-free diet for at least two weeks.
• Post-surgery, overeating is curbed because
  exceeding the capacity of the stomach causes
  nausea and vomiting.

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Advantages

1. Stomach tends to function normally so most food
   items can be consumed in small amounts.
2. Removes the portion of the stomach that produces
   the hormones that stimulates hunger (Ghrelin).
3. No dumping syndrome because the pylorus is
   preserved.
4. Minimizes the chance of an ulcer occurring.
5. The chance of intestinal obstruction, anemia,
   osteoporosis, protein deficiency and vitamin
   deficiency are significantly reduced.
6. Results appear promising as a single stage
   procedure for low BMI patients (BMI 3545 kg/m2).

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Complications

• Leakage can be treated easily by performing a
  second procedure that helps in strengthening the
  staple lines.
• Stapple line bleeding
• Gastroesophageal Reflux It might be happening
  because of the changes in the shape of the
  stomach.
• Gastric Fistula may occur and another surgery
  may be needed to treat this condition.

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• Narrowing of Stoma A tube used for dilation is
  passed from the mouth to pass into the stomach as
  this expands the stoma.
• Hernia Another surgery may be needed to repair
  this condition.
• Malabsorption of Vitamins and Minerals
• Anemia and vitamin B12 deficiency can cause
  neurological diseases.
• Changes in the absorption of phosphates, calcium
  and oxalates can result in kidney stone
  formation.
• Similarly, deficiency of vitamin D and calcium
  can also give rise to different disorders of the
  bone.

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• Microbial infections as pneumonia and
  intraabdominal abscess are most common.
• Deep vein thrombosis (DVT).
• Hair loss.
• Hair thinning.
• Mood swings.
• General feeling of weakness.
• Dry skin .

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Outcomes of SG other bariatric procedures
GB AGB BPD BPDD switch SG
Weight loss 65-70 (EBW) 50 (EBW) 70 70 50-80
Morbidity 5 5 5 5-10 5
Mortality 0.5-1 0.1 1 1-5
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