Laparoscopic Sleeve Gastrectomy: Indications, Techniques, and Success Rates

Laparoscopic Sleeve Gastrectomy (LSG) has become a cornerstone in the treatment of morbid obesity, offering a minimally invasive, yet highly effective solution for weight loss. Over the past decade, LSG has gained popularity due to its favorable outcomes, reduced complication rates, and the absence of an intestinal bypass, which lowers the risk of nutritional deficiencies compared to other bariatric procedures. This article delves into every aspect of LSG, from indications to recent advancements, providing a detailed resource for surgeons.

Indications

LSG is primarily indicated for patients with:

1. Morbid Obesity: Defined as a BMI ≥ 40 kg/m², or ≥ 35 kg/m² with associated comorbidities such as diabetes, hypertension, or obstructive sleep apnea.
2. Failure of Non-Surgical Methods: Patients who have not achieved significant or sustained weight loss through diet, exercise, and medical management.
3. Need for Reduced Surgical Risk: LSG is often preferred in patients with high surgical risk due to its relatively shorter operative time and lower complexity compared to Roux-en-Y gastric bypass (RYGB).

Additionally, LSG is considered for patients who:

• Require a staged approach to weight loss surgery.
• Have a high BMI (>50 kg/m²) where LSG may be the first step before more complex procedures.
• Have contraindications to other forms of bariatric surgery.

Preoperative Evaluation

A thorough preoperative evaluation is critical to identify potential risks and optimize patient outcomes. The evaluation typically includes:

1. Medical History and Physical Examination: Assessing for obesity-related comorbidities, previous abdominal surgeries, and general fitness for surgery.
2. Nutritional Assessment: Ensuring patients are nutritionally prepared and have adequate vitamin and mineral reserves. A low-calorie diet may be recommended preoperatively to reduce liver size and intra-abdominal fat.
3. Psychological Evaluation: Identifying psychiatric disorders, eating disorders, or unrealistic expectations that could impact postoperative outcomes.
4. Cardiopulmonary Assessment: Screening for conditions such as obstructive sleep apnea, coronary artery disease, or pulmonary hypertension, which may increase perioperative risk.
5. Laboratory Tests: Routine blood work including complete blood count, liver function tests, kidney function tests, and coagulation profile.
6. Imaging Studies: Abdominal ultrasound or CT scan to evaluate liver size, presence of gallstones, or other abdominal pathologies.

Contraindications

LSG is contraindicated in patients with:

1. Severe Gastroesophageal Reflux Disease (GERD): LSG can exacerbate GERD symptoms, making it unsuitable for patients with severe reflux.
2. Uncontrolled Psychiatric Disorders: Conditions such as severe depression or psychosis may impair the patient’s ability to comply with postoperative care.
3. Drug or Alcohol Abuse: These conditions increase the risk of postoperative complications and poor outcomes.
4. Lack of Comprehension of Risks and Lifestyle Changes: Patients must demonstrate an understanding of the surgery and the lifelong commitment required for success.

Surgical Techniques and Steps

LSG involves the creation of a tubular stomach by resecting the greater curvature. The procedure is performed laparoscopically, offering the advantages of reduced pain, faster recovery, and lower complication rates. The key steps include:

1. Patient Positioning and Anesthesia: The patient is positioned in a supine position with slight reverse Trendelenburg. General anesthesia is administered, and a nasogastric tube is placed.
2. Port Placement: Typically, five ports are used. A camera port is placed at the umbilicus, with additional ports for the surgeon's and assistant’s instruments.
3. Liver Retraction: A liver retractor is used to elevate the left lobe of the liver, providing better access to the stomach.
4. Dissection of the Greater Curvature: The greater curvature is mobilized starting from the antrum up to the angle of His. This is done using an energy device to divide the short gastric vessels and the gastroepiploic artery.
5. Bougie Insertion: A bougie (usually 36-40 Fr) is inserted along the lesser curvature to guide the resection and ensure uniformity of the gastric tube.
6. Gastric Resection: The stomach is resected using a linear stapler, starting approximately 5-7 cm from the pylorus and proceeding upward toward the angle of His. Stapler loads with buttressing material are often used to reinforce the staple line.
7. Hemostasis and Leak Test: The staple line is inspected for bleeding, which is controlled using clips or sutures. A leak test is performed using methylene blue or air insufflation.
8. Specimen Extraction: The resected portion of the stomach is removed through the largest port.
9. Closure: The ports are closed, and the patient is extubated and transferred to the recovery room.

Postoperative Care

Postoperative management focuses on pain control, early ambulation, and gradual reintroduction of nutrition. Key aspects include:

1. Pain Management: Multimodal analgesia is employed, often with a combination of opioids and non-opioid analgesics.
2. Fluid Management: Patients begin with clear liquids on the day of surgery, progressing to full liquids and pureed foods over the next few weeks.
3. Nutritional Support: A dietitian guides the patient through the gradual reintroduction of solid foods, emphasizing protein intake and supplementation of vitamins and minerals, particularly vitamin B12, iron, calcium, and vitamin D.
4. Monitoring for Complications: Close monitoring for signs of leak, hemorrhage, or deep vein thrombosis (DVT) is essential. Early ambulation and use of compression devices or anticoagulants help prevent DVT.

Possible Complications

While LSG is generally safe, complications can occur, including:

1. Staple Line Leaks: The most serious complication, usually occurring within the first few days postoperatively. Early detection and management are crucial, often requiring reoperation or endoscopic intervention.
2. Hemorrhage: Bleeding from the staple line or other sources within the abdomen may necessitate reoperation or blood transfusion.
3. Strictures: Narrowing at the proximal or distal end of the sleeve may cause dysphagia or vomiting, often managed with endoscopic dilation.
4. Gastroesophageal Reflux: LSG can exacerbate or lead to new-onset GERD, which may require medical or surgical management.
5. Nutritional Deficiencies: Long-term deficiencies in iron, vitamin B12, and other micronutrients are possible, requiring ongoing supplementation.

Different Techniques

Various techniques and modifications have been developed to enhance the safety and efficacy of LSG. These include:

1. Single-Port LSG: A minimally invasive approach using a single incision, offering cosmetic benefits but with a steeper learning curve.
2. Robot-Assisted LSG: Provides enhanced precision and dexterity, particularly in complex cases, but at a higher cost.
3. Endoscopic Sleeve Gastroplasty: A non-surgical alternative using an endoscopic suturing device to reduce stomach volume, suitable for lower BMI patients.

Prognosis and Outcome

LSG results in significant weight loss and improvement in obesity-related comorbidities. On average, patients lose 60-70% of their excess weight within the first 12-18 months. Long-term studies show sustained weight loss and resolution or improvement in conditions such as type 2 diabetes, hypertension, and obstructive sleep apnea.

Alternative Options

Alternative bariatric procedures include:

1. Roux-en-Y Gastric Bypass (RYGB): A more complex procedure with higher risk but superior results in resolving diabetes.
2. Adjustable Gastric Banding (AGB): A less invasive option with adjustable restriction but lower overall efficacy.
3. Biliopancreatic Diversion with Duodenal Switch (BPD/DS): Offers the highest weight loss potential but with greater risk of malnutrition.

Average Cost

The cost of LSG varies widely, depending on the geographic location, surgeon's experience, and hospital facilities. In the United States, the average cost ranges from $15,000 to $25,000, including preoperative evaluation, surgery, and postoperative care. Costs may be lower in other countries or higher in specialized centers.

Recent Advances

Recent advances in LSG focus on improving outcomes and reducing complications. These include:

1. Enhanced Recovery After Surgery (ERAS) Protocols: Implementing ERAS protocols has shortened hospital stays and reduced complication rates.
2. Staple Line Reinforcement: The use of buttressing materials or over-sewing the staple line to reduce leaks and bleeding.
3. Intragastric Balloon as a Bridge to Surgery: For super-obese patients, intragastric balloons can reduce weight and surgical risk before LSG.
4. Ongoing Research on Gut Hormones: Studies on how LSG affects gut hormones such as ghrelin and GLP-1, contributing to weight loss and metabolic improvements.

Conclusion

Laparoscopic Sleeve Gastrectomy is a transformative procedure in bariatric surgery, offering substantial weight loss with a favorable safety profile. While it is not without risks, careful patient selection, meticulous surgical technique, and comprehensive postoperative care can optimize outcomes. As techniques continue to evolve, LSG remains a critical tool in the fight against obesity.