Re-Sleeve Gastrectomy

Obesity Surgery, 16, 1535-1538 Modern Surgery Re-Sleeve Gastrectomy Aniceto Baltasar; Carlos Serra; Nieves Pérez; Rafael Bou; Marcelo Bengochea The Surgical Service, “Virgen de los Lirios” Hospital, Alcoy, Alicante, Spain Background: Laparoscopic sleeve gastrectomy (LSG) started as the restrictive part of the more complex laparoscopic duodenal switch (LDS) operation. There is no long-term experience with the isolated LSG. The main concern about the isolated LSG is the possibility of dilatation of the gastric pouch, long-term loss of restrictive function and weight regain. Laparoscopic re-sleeve gastrectomy (LRSG) has been used sparingly, but it also may become a possibility if more patients have the isolated LSG. Methods: 2 patients with BMI 58 and 65 respectively, underwent LSG as the first stage of the LDS. Later, when the patients regained some weight and their gastric pouch was found to be too large, the LRSG/DS was done. Results: The patient with BMI 58 had an initial drop to BMI 34 and regained weight to BMI 46, but after the LRSG/DS her BMI is 36 at 4 months. The BMI patient with BMI 65 had a drop to BMI 42, and after the LRSG/DS his BMI is 33 at 3 months later. Conclusion: LRSG may become necessary after gastric tube dilatation or insufficient original gastric volume reduction. LRSG is feasible, available and easy to perform when the resulting gastric pouch is too large or dilates after the original LSG. Key words: Morbid obesity, obesity surgery, laparoscopy, sleeve gastrectomy, re-operation, duodenal switch the more complex laparoscopic duodenal switch (LDS) operation, and became a reality where the laparoscopic approach to the super-super-obese was found to be a too complex operation.1-3 There is no long-term experience with the LSG. The main concern about the isolated LSG is the possibility of dilatation of the gastric pouch, long-term loss of the restrictive function and weight regain. LSG has proved to be a more effective operation in the super-obese patients than the gastric balloon.4 Duodenal switch (DS) is our mainstay bariatric operation since 1994 (545 open cases), and now is done routinely laparoscopically (LDS) hand-sewn since 2000 (304 cases). LSG has been performed since 2003 (72 patients).5-7 LSG is purely restrictive and our indications are: 1) super-obese patients (BMI>55) as a first stage for the LDS; 2) patients with BMI >40 with severe medical disease (cirrhosis, AIDS, Crohn’s); 3) low BMI patients (35-43) with a major co-morbidity; 4) patients with lap-band removal; and 5) the morbidly obese adolescent.5 Laparoscopic re-sleeve gastrectomy (LRSG) is possible if the stomach dilates or if the original LSG left a higher volume stomach than desirable. Introduction Laparoscopic sleeve gastrectomy (LSG) is a new tool in the surgical management of the morbidly obese and the super-obese. It is the restrictive part of Reprint requests to: A. Baltasar, MD, Servicio de Cirugía General, Hospital Virgen de los Lirios, Polígono de Caramanxel s/n, 03804, Alcoy, Alicante, Spain. E-mail: baltasar_ani@gva.es or abaltasar@seco.org © FD-Communications Inc. Case Reports Patient 1. A 48-year-old female with BMI 58 kg/m2 underwent an LSG in December 2002. She reached her lowest BMI of 34 at 18 months after the LSG, and then regained weight to a BMI of 46. On reviewing the immediate post-LSG GI study (Figure 1A), a too large Obesity Surgery, 16, 2006 1535 Baltasar et al upper pouch was detected, that increased in diameter to more than 4 cm (Figure 1B). She then underwent the LRSG with DS in 2006. At the LRSG, the dilated pouch was resected without difficulty. Now, the GI study shows a significant reduction of the pouch diameter (Figure 1C) and the patient has significant restriction clinically. At 4 months after this last surgery, her BMI is 33, and her percent excess BMI loss (%EBMIL) compared to the original LSG, is 67.8%. Patient 2. A 32-year-old male with BMI 65 had a LSG in 2004. His postoperative GI study is shown in Figure 2A. Nine months later he had a BMI of 41. In 2006, with BMI 42, the GI study showed antral dilatation. He underwent a LRSG plus DS, and 6 months later his BMI is 27.6. Total %EBMIL is 93.3%. Discussion LSG was initially indicated as a first-stage operation for the LDS in super-obese patients to decrease morbidity and mortality.1-3 LSG produces weight loss by a double mechanism: 1) early satiety as described Marceau,8 and 2) reduction of the ghrelin levels.9-13 The size of the gastric pouch has not been standardized. Gagner1 used a 60-F boogie and a gastric pouch volume of 150-200 ml. This pouch size, in our opinion, is too large. We use a 12-mm diameter boogie (36-F) and our measured pouches are 50-60 cc (Figure 3). A The entire greater curvature of the stomach, in our technique, is completely devascularized from the left crus of the diaphragm distally to 2 proximal to the pylorus. All gastro-pancreatic attachments are divided and the posterior part of the antrum is free. A 12-mm diameter stent is guided along the lesser curvature of the stomach and passed (if possible) distal to the pylorus. A clamp holds the boogie in the proximal duodenum and the anesthetist pulls the bougie at the mouth applying tension, which straightens the lesser curvature. Stapling and division are done twice with green staplers 4.5-cm in length, starting just proximal to the pylorus to reach the incisura angularis. From there on, we use 6-cm long staplers up to the angle of His and lateral to the fat-pad of the esophago-gastric junction. Because restrictive operations often fail in the long-term, care should be taken to prevent dilatation in the LSG. Very small pouches are a must, and on reviewing the two cases presented above, the restriction was not properly achieved. Large pouches are more likely to occur at the two ends of the stapleline, the esophago-gastric junction and the antrum. LRSG has been rarely reported.14,15 If weight regain occurs after LSG, there are two options: 1) isolated LRSG if dilatation of the stomach is >4 cm in diameter is shown by GI series study,15 and 2) conversion to a Roux-en-Y gastric bypass or, possibly better, to a LDS. B Figure 1. Patient 1. A) After LSG; B) Before LRSG; C) After the LRSG. 1536 Obesity Surgery, 16, 2006 C Re-Sleeve Gastrectomy A B C Figure 2. Patient 2. A) After LSG; B) Weight regain and antral dilatation; C) LRSG and antral narrowing. At this time, our LSG patients have had very good %EBMIL of >65% in most, but these are short- or intermediate-term results. Only long-term results (>5 years) will prove if the isolated LSG will be a permanently effective procedure. Advantages of the LSG are: 1) the stomach is reduced in volume but functions normally, so most food items can be consumed, albeit in small amounts; 2) the portion of the stomach that produces the hor- Figure 3. Postoperative upper GI series after a proper LSG. mones that stimulate hunger (ghrelin) is eliminated; 3) no dumping syndrome occurs because the pylorus is preserved; 4) the chance of an ulcer occurring is minimized; 5) by avoiding the intestinal bypass, the chance of intestinal obstruction, anemia, osteoporosis, protein and vitamin deficiency are almost eliminated; 6) it is very effective as a first-stage operation for high BMI patients (BMI>55 kg/m2); 7) limited results appear promising as a single-stage procedure for low BMI patients (BMI 35-45 kg/m2); 8) it is an appealing option for people with existing anemia, Crohn’s disease and numerous other conditions that make them too high-risk for intestinal bypass procedures; 9) it can be performed laparoscopically in patients weighing >225 kg; 10) no foreign body; 11) less operating time; 12) easy recovery; 13) few, if any, side-effects; 14) it is an excellent alternative to the adjustable gastric band and gastric balloon that need frequent adjustments and are foreign bodies; 15) if there is insufficient weight loss, the DS can then be performed easily by laparoscopy because no further supramesocolic dissection is required; and 16) it is a very good operation for morbidly and super-obese adolescents, who possibly should avoid more aggressive surgery. Disadvantages of the LSG are: 1) the potential for inadequate weight loss or weight regain (While this is true for all procedures, it is theoretically more possible with operations that do not include an intestinal bypass); 2) higher BMI patients will most likely need to have a second-stage operation later to help lose the Obesity Surgery, 16, 2006 1537 Baltasar et al rest of the weight. Two stages may be safer and more effective than one operation for high BMI patients; 3) soft calories such as ice cream, milk shakes, etc. can be absorbed and may slow weight loss; 4) this procedure does involve gastric stapling, and hence leaks and other complications related to stapling may occur; 5) because stomach is removed, it is not reversible, but it can be converted to almost any other weight loss procedure; 6) it is considered investigational by some surgeons and insurance companies; and 7) long-term results are not available. LSG should be considered as an important advantage compared with an open sleeve gastrectomy operation. Because adhesions are significantly reduced compared with the open technique, LRSG is more likely to be done easily, as occurred in our two cases. LRSG will be a repeat strategy for some patients. The LRSG is achieved with very little trauma and early recovery. LRSG may also be used as a recurring procedure in some patients. References 1. Regan JP, Inabnet B, Gagner M et al. Early experience with two-stage laparoscopic Roux-en-Y gastric bypass as an alternative in the super-super obese patient. Obes Surg 2003; 13: 861-4. 2. Almogy G, Crookes PF, Anthone G. Longitudinal gastrectomy as a treatment for the high-risk superobese patient. Obes Surg 2004; 14: 492-7. 3. Fazylov R, Savel R, Horovitz J et al. Association of super-super-obesity and male gender with elevated mortality in patients undergoing the duodenal switch procedure. Obes Surg 2005; 15: 618-23. 4. 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