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Laparoscopic Sleeve Gastrectomy—A Novel Surgical Tool for Weight Loss in morbidly Obese Patients
in hospital was 7.2 days. No early mortalities or compli- gastric staple line, spleen, liver, or abdominal wall at the
cations were reported. At 1 year after LSG, an EWL of sites of trocar entry. A number of buttressing materials
51% and a BMI decrease to 41 was reported in the 30% are commercially available to attempt to reduce the rate
of patients who completed follow-up. of bleeding from the staple line. Several authors have
Similar results were demonstrated in a retrospec- described oversewing the long staple line, whereas
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tive study by Baltasar et al, involving 31 patients who others have used buttressed staples (i.e., Gore Seamguard
had undergone LSG for various reason. There were Bioabsorbable Staple Line Reinforcement) or fibrin glue
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no instances of deep vein thrombosis or pulmonary as a sealant and were able to demonstrate significantly
embolism, leak or pneumonia. However, there were less intraoperative blood loss in the buttressed staple
two instances of trocar-related intraabdominal bleed- line group (120 vs 210 mL, p < 0.05). Albanopoulos and
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ing, with one leading to death. Mean EWL ranged colleagues, however, did not observe a significant dif-
from 56.1% (at 4–27 months) in the super-obese patients ference in their rate of postoperative bleeding between
to 62.3% (3–27 months follow-up) in the lower BMI patients with staple line suturing or buttressing with
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patients with significant comorbidities. Himpens et al Gore Seamgard after LSG.
published a prospective randomized study involving In our series, there were three cases of bleeding from
40 patients undergoing LSG. With a median initial BMI the staple line of which two were managed with the tita-
nium clips and one required staple line suturing. We rou-
of 39 (30–53), their 3-year follow-up data found a median tinely did not reinforce the suture line. The other minor
weight loss of 29.5 kg (1–48), median BMI decrease of bleeding from short gastric vessels (one case) and one
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27.5 kg/m (0–48), and a median percent of EWL of 66% from liver during retraction were managed conservatively.
(–3.1 to 152.4) after LSG. We did not encounter any case of intraluminal bleeding
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Milone et al retrospectively compared their experi- and any case of bleeding in the postoperative period.
ence with 20 LSG patients (BMI > 50) to that of 57 Bio- Gastric leak is the most serious and dreaded complica-
Enterics Intragastric Ballons. In LSG patients, the only tions of LSG. It occurs in up to 5% of patients following
complication was a trocar site infection. Laparoscopic LSG. 22,38 An early leak is generally diagnosed within
sleeve gastrectomy not only produced significantly more the first 3 days after surgery, whereas a delayed leak is
weight loss but also had fewer complications in this usually diagnosed more than 8 days after surgery. 40
limited study. In a study by Kolakowski et al, a combi nation of
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Laparoscopic sleeve gastrectomy as a sole weight clinical signs of fever, tachycardia, and tachypnea was
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loss procedure was also examined by Langer et al. At found to be 58.33% sensitive and 99.75% specific for
6 months, mean EWL among all 23 patients was 46%, detection of anastomotic leaks clinically. In the presence
and it was 56% at 1 year. Two patients required conver- of a leak, an abdominal washout laparoscopically with
sion to RYGB. surgical repair of the leak (if technically feasible) and
In our study the percentage of EWL was 4.31, 8.14, 16.28, feeding jejunostomy should be performed.
and 30.61% at 1st, 2nd, 4th, and 12th weeks respectively, Treatment of delayed gastric leak is more challenging
which is significant and in consistent with other studies. and includes conservative or surgical management. This
Similarly, the mean BMI also reduced substantially in depends on the patient’s hemodynamic condition and
accordance with the earlier studies. It is expected that the on physical and radiological findings. In the absence of
loss of excess weight may be even more if patients follow hemodynamic instability and physical findings sugges-
the nutritional guidelines strictly, which is high-protein tive of peritonitis, conservative management, including
low-calorie diet and regular exercise (Graph 2). intraluminal stenting, should be initiated. Himpens
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A recent survey conducted at the First International et al reported their experience in the management of
Consensus Summit for Sleeve Gastrectomy asked “Is LSG 29 patients with gastric leak after sleeve gastrectomy

indicated as a primary procedure in patients with a BMI with stenting in which the stents were left in situ on
> 40 or BMI > 35 with comorbidities?” Of the respondents, average for 7 weeks. Immediate success was observed in
58% completely agreed, 19% somewhat agreed, 8% had 19 patients after placement of the first stent, whereas five
no opinion, 14% somewhat disagreed, and 0% completely patients required placement of a second stent. In a septic
disagreed. 36 patient with radiological evidence of a leak with diffuse
intraabdominal fluid collections, surgical drainage of the
COMPLICATIONS fluid collection is warranted.

The risk of postoperative bleeding has been reported
to be between 1 and 6% after LSG. 37,38 The bleeding Abscess
may be intraluminal or extraluminal and are managed Intraabdominal abscess is another known complica-
conservatively. The extraluminal bleeding may be from tion after LSG. In a series of 164 patients undergoing
World Journal of Laparoscopic Surgery, September-December 2016;9(3):107-113 111