OBES SURG DOI 10.1007/s11695-014-1524-3
Laparoscopic Sleeve Gastrectomy for Morbid Obesity with Intra-operative Endoscopy: Lessons We Learned After 100 Consecutive Patients Alexandrou Andreas & Michalinos Adamantios & Athanasiou Antonios & Rosenberg Theofilos & Tsigris Christos & Diamantis Theodoros
# Springer Science+Business Media New York 2014
Abstract Background 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. Methods Between 2004 and 2013, 100 patients have undergone laparoscopic or robotic sleeve gastrectomy with intraoperative endoscopic guidance. Technical aspects of the operation, results concerning morbidity, progressive weight loss, and resolution of co-morbidities were retrospectively reviewed. Results 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. Conclusion 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.
A. Andreas (*) : M. Adamantios : A. Antonios : R. Theofilos : T. Christos : D. Theodoros 1st Surgery Department, Laikon General Hospital, National and Kapodistrian University of Athens, Agiou Thoma 17, Athens, Greece e-mail: [email protected]
Keywords Laparoscopic sleeve gastrectomy . Robotic sleeve gastrectomy . Upper gastrointestinal endoscopy . Excess weight loss . Co-morbidities
Introduction Morbid obesity is acknowledged as one of the most significant health problems throughout developed countries during the last 30 years  and bariatric surgery is considered its most effective means of treatment. Strategies for the surgical treatment of morbid obesity include restriction of ingested food, malabsorption of its caloric potential, or a combination of these mechanisms. Different surgical techniques can vary considerably in their level of difficulty and can have accordingly variable immediate postoperative and long-term results . The use of laparoscopic sleeve gastrectomy (LSG) for the treatment of super morbid obesity was first reported back in 2003 by Regan et al.  as the first step of a two-stage surgical strategy. Since then, it has evolved as a safe and effective independent surgical option for the treatment of morbid obesity, characteristics that have made it popular both among patients and surgeons [4–6]. Nowadays, it represents the second most commonly performed bariatric procedure, following Roux-en-Y gastric bypass (RYGB). Its rate currently runs at 27.8 %, whereas 3 years ago, it was only 5.3 %, and less than 10 years ago, the operation was considered experimental . In our Department of Surgery, we have been using LSG for the treatment of morbid obesity since 2004. Very early in our experience, we decided to apply intra-operative endoscopic guidance for the calibration of the gastric sleeve instead of the commonly used bougie and we have already reported our initial experience . Since 2008, we have also used the Da
Vinci Surgical System for the performance of LSG (robotic sleeve gastrectomy, RSG) and we were actually among the first to report our initial experience with it, with equally good results as with conventional LSG . The aim of this study is to report our experience after 100 consecutive patients who have undergone minimally invasive sleeve gastrectomy (SG) with intra-operative endoscopic guidance and try to identify any advantages and disadvantages of the technique which could affect the immediate and long-term post-operative results.
Patients and Methods From January 2004 to January 2013, a total of 100 morbidly obese patients underwent LSG at our department with the use of intra-operative endoscopy. The operations were performed either as the first part of a planned two-stage weight reduction operative strategy for morbid obesity or as a stand-alone option for the definitive treatment of morbid obesity. Preoperative work-up was extensive and included blood tests, chest x-ray, abdominal ultrasound, echocardiography, electrocardiography, sleep apnea study, esophagogastroscopy and endocrinological and psychiatric tests. Twenty-one of our patients were males and 79 were females. Their mean age was 50.3±7.6 (range 38.3–72.3), their mean weight was 141.2±27.8 (range 93–237) and their mean body mass index (BMI) was 38.8±11.1 (range 18–64). In total, 71 patients presented co-morbidities, 19 diabetes, 54 hypertension, 23 sleep apnea, and 1 chronic pulmonary obstructive disease. Our technique has already been reported [7, 8]. Briefly, our main modification of the so-called standard technique is that we used intra-operative endoscopic guidance instead of a bougie in order for calibration of the gastric sleeve. In this way, an inside view of the staple line and the performance of an air leak test was also possible (Fig. 1). During the study period, two different endoscopes were used. Until October 2008, we used a FUJINON EG-200 FP type S (FUJI Photo Optical, Japan). The outer diameter of the scope was 9.8 mm, equivalent to 29Fr bougie, and the working length was 103 cm. From then on, we have been using a KARL STORZ 13807 PKS. The outer diameter of the scope is 10.1 mm, equivalent to 30Fr bougie. The endoscope was placed after the stomach had been fully mobilized. In order to avoid curving of the gastroscope against the major instead of the lesser curvature, we regularly try to introduce the scope to the first part of the duodenum, we anchor it there, and we slightly retract it so as to bow it against the lesser curvature. Before we withdraw the nasogastric tube, we aspirate all the air from the stomach and thus we avoid the underexposure of the surgical field. With the gastroscope in proper position (Fig. 2, left), the division of the stomach is performed with
Fig. 1 Endoscopic view of sleeve by intra-operative endoscopic image. The inner part of the staple line can be seen at the right side of the picture
the use of the linear stapler (Echelon 60 endopath stapler, endoscopic linear cutter-straight, Ethicon Endo-surgery Inc.) starting 4 cm proximally to the pylorus. We underline the importance of a complete mobilization of the gastric fundus before the transection of the stomach. The staple line was always reinforced with buttressing material (mostly with GORE SEAMGUARD bioabsorbable staple line reinforcement, W. L. GORE and Associates Inc., currently with Peristrips). After the completion of the division of the stomach, the endoscope was pulled slowly outwards in order to carefully inspect the staple line for any bleeding or suspicions for disruption points (Fig. 2, right). Any bleeding or suspicions for leak points was strengthened with clips. Both an air bubble and a dye (water-diluted povidone solution) leakage test were also performed after the withdrawal of the scope and the reinsertion of the nasogastric tube. The procedure was performed on 24 patients with the use of the Da Vinci Surgical System, but the various technical details were identical. According to our protocol, a leakage test was performed 48 h post-op with a water-soluble contrast medium study. The patients were allowed a semi-liquid diet on the third postoperative day and were subsequently discharged on the fourth post-operative day. Patients were re-examined in the outpatient clinic after 1 week and 1, 3, and 6 months, and then on a yearly basis. They were advised to take oral multivitamin supplements daily. The follow-up examinations apart from the rest of the tests included also blood tests for calcium, parathormone, vitamin D, folic acid, and vitamin B12. Weight loss was calculated as the percentage of excess weight loss (%EWL) based on the Metropolitan life tables 1983, of height and weight. Resolution of co-morbidities was defined as the discontinuation of previous treatment. All statistical analyses were performed using the statistical program SPSS 20.0. Values are expressed as mean±standard deviation of means. T test was applied for all statistical comparisons.
OBES SURG Fig. 2 Endoscope in proper position inside the stomach, before division (left) and staple line (right)
Results By the end of 2012, 100 patients had undergone minimally invasive SG with the use of intra-operative endoscopic guidance. The operation was offered to patients with BMIs 50 kg/m2, namely 46 patients, lost less in comparison to those with BMIs less than 50 kg/m2, namely 45.8±15.3 vs 57.0±14 % (p