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European Review for Medical and Pharmacological Sciences 2016; 20: 4930-4942

Sleeve gastrectomy: have we finally


found the holy grail of bariatric surgery?
A review of the literature
I. KEHAGIAS¹, A. ZYGOMALAS¹, D. KARAVIAS¹, S. KARAMANAKOS²

¹Department of General Surgery, Nutrition Support and Morbid Obesity Unit,


University Hospital of Patras, Greece
²Department of General Surgery, Basildon and Thurrock University Hospitals, Essex, UK

Abstract. – OBJECTIVE: Laparoscopic sleeve fully classified as a disease by WHO. Bariatric


gastrectomy has become one of the most com- surgery can effectively treat obesity and also
monly performed bariatric operations. It is es- improve or even resolve a number of related co-
sentially a restrictive bariatric operation; how-
ever, a series of hormonal changes occurring
morbidities, offering patients a better life. Based
postoperatively contribute to decreased appe- on recent studies, LSG is not only a safe, but also
tite and reduced food intake. an effective bariatric procedure with long-lasting
PATIENTS AND METHODS: This is a literature results2. The aim of this report is to approach the
review of recent articles published on Pubmed, role of sleeve gastrectomy as a contemporary
Medline and Google Scholar databases in English. bariatric procedure through a comprehensive and
RESULTS: Although, laparoscopic sleeve gas- concise review regarding various aspects of this
trectomy is commonly performed worldwide,
there is still a lack of standardization regarding promising technique. Articles on sleeve gastrec-
the surgical technique. Standardizing the surgi- tomy, published on Pubmed, Medline and Google
cal technique is essential in order to minimize Scholar databases in English were thoroughly
postoperative complications and offer patients revised and included in the discussion.
the best long-term weight loss.
CONCLUSIONS: Laparoscopic sleeve gas-
trectomy appears to be an effective bariatric op-
eration. It is relatively easy to perform, well tol-
Historical evolution
erated by the patients and very effective regard-
ing long-term excessive weight loss and reso- Sleeve gastrectomy was first performed by
lution of the comorbidities, with minimum nutri- Hess in 1988 as part of his biliopancreatic diver-
tional deficiencies. sion with the duodenal switch (BPD-DS) pro-
cedure, adapted from Scopinaro’s biliopancre-
Key Words atic diversion (BPD) and DeMeester’s duodenal
Bariatric surgery, Sleeve gastrectomy, Laparoscopy- switch (DS) procedures3-5. Later in 1991 and
ic surgery, Morbid obesity, Gastric sleeve.
1993 Marceau also proposed his modifications on
Scopinaro’s biliopancreatic diversion that effec-
tively included early forms of sleeve gastrectomy
Introduction variations6,7. With the evolution of laparoscopic
surgery during the 1990s, Gagner performed es-
Laparoscopic sleeve gastrectomy (LSG) has sentially the first laparoscopic sleeve gastrectomy
become one of the most commonly performed as part of BPD-DS in 19998. As a less demand-
bariatric operations over the last years1. With ing technique, sleeve gastrectomy quickly gained
more than 94.000 procedures performed in 2011, popularity early in the 21st century. Initially, it
LSG has not only gained popularity, but also be- was performed as a first step intervention for
came the second most commonly bariatric oper- super-obese patients (BMI > 60 kg/m2), before
ation performed after gastric bypass1. With more definite intervention was undertaken with either
than 1.9 billion overweight and over 600 million gastric bypass or biliopancreatic diversion proce-
obese people worldwide in 2014, obesity is right- dures9,10. Nowadays laparoscopic sleeve gastrec-

4930 Corresponding Author: Ioannis Kehagias, MD, Ph.D; e-mail: ikehag@yahoo.gr


Sleeve gastrectomy, a review

tomy (LSG) is considered a principal laparoscop- offering patients considerable excess weight loss
ic bariatric procedure, mainly due to the many (%EWL)17-19. Boza et al20 reported, after 1000
advantages it possesses. consecutive cases, that the %EWL at 1, 2 and 3
years had been 86.6%, 84.1% and 84.5% respec-
tively. Similarly, Rawlins et al21 found a %EWL
Mechanisms of action of 86% at 5 years. In contrast to these very
promising results, most publications agree that
The LSG is essentially a restrictive bariatric patients undergoing LSG achieve a 60%EWL at
operation. Weight loss is achieved by drastically 5 years22-27. After an initial high %EWL, most
reducing the gastric volume, which in turn leads series report some weight regain after the second
to reduced food intake. In addition, a series of year19. Respectively, Himpens et al25 and D’Hondt
hormonal changes occurring postoperatively in et al28 observed that patients regain weight after
bariatric patients, contribute to decreased appe- 5 years, with the % EWL dropping below 60%.
tite, reduced food intake and long-term weight However, Sarela et al29 reported a %EWL of 69%
loss (Figure 1)11, 12. Ghrelin, a hormone produced at 9 years, the longest follow-up to date.
primarily by the oxyntic cells of the fundus of
the stomach during fasting, stimulates appetite by
increasing the expression of the orexigenic hypo- Nutrient deficiencies
thalamic neuropeptide Y (NPY)11. By removing
the gastric fundus, patients undergoing sleeve It is well documented that obese patients are
gastrectomy have markedly decreased levels of generally malnourished, mainly due to a non-var-
ghrelin and suppressed appetite respectively13. ied diet high in fats and carbohydrates and low
Peptide YY (PYY), a hormone produced post- in quality protein products, dairy and vegetables.
prandially from the gut, inhibits the release of Most nutrient and micronutrient deficiencies per-
NPY and has an anorectic effect14. PYY is nota- sist postoperatively in patients undergoing bar-
bly increased after sleeve gastrectomy, leading iatric surgery and as a result multivitamin sup-
to prolonged satiety and reduced food intake13. plementation is necessary for these patients30,31.
Glucagon-like peptide-1 (GLP-1) is secreted from However, nutritional deficiencies vary greatly
the enteroendocrine L-cells in the intestine as a between different bariatric operations, with LSG
response to food indigestion. GLP-1 stimulates having only a minimal impact on the nutrient
insulin release, inhibits glucagon secretion and status22,32,33. Similarly to other types of bariatric
has a satiating effect. Both rapid gastric emptying procedures, most commonly observed nutrient
and postprandial hyperglucagonemia observed deficiencies like iron, folate and thiamine persist
after sleeve gastrectomy lead to increased GLP-1 postoperatively, but can be easily resolved with
levels15, 16. a daily multivitamin supplementation22,32-35. Iron
deficiency and anemia in particular, commonly
seen in bariatric patients, are also present after
Weight loss after LSG LSG. However, the risk for anemia after LSG is
lower compared to the other type of procedures,
A major advantage of LSG is that despite when the iron supplement is administered post-
being an easy, quick and safe bariatric proce- operatively33,36. Vitamin D deficiency is common
dure, it is also an effective surgical technique, among obese patients due to malnutrition and
limited sun exposure. Postoperative hypovita-
minosis D, however, is not common after LSG
due to loss of adipose tissue and adequate supple-
mentation22,32. Respectively vitamin B12 deficien-
cy is also not common after LSG as compared to
gastric bypass and BPD22,32,34,36,37. Vitamin B12 is
absorbed in the terminal ileum when banded to
intrinsic factor, which is produced from the pari-
etal cells in the antrum and duodenum. As com-
pared to other malabsorptive bariatric operations,
Figure 1. Hormonal changes occurring postoperatively af- where the duodenum is bypassed, the uptake of
ter LSG. vitamin B12 is not disturbed in LSG32,36.

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I. Kehagias, A. Zygomalas, D. Karavias, S. Karamanakos

Improvement in metabolic changes faction postoperatively and a significant number


(diabetes) of them change their eating habits to a healthier
diet over time56. Furthermore, due to the quick
Besides excess weight loss (%EWL), LSG rehabilitation and the adequate weight loss, phys-
has a positive effect on diabetes. Several stud- ical activity, sexual life and self-esteem are also
ies report that type 2 diabetes mellitus (T2DM) improved postoperatively52. Additionally, in con-
resolves in a significant percentage of patients trast to laparoscopic adjustable gastric banding
undergoing LSG19,38,39. Improvement and resolu- (LAGB) procedure, which is also considered to
tion rates as high as 86% of patients are reported, be safe and one of the least invasive bariatric
which are similar to those seen after RYGB and operations, no foreign bodies are used during
superior to LAGB22,40-44. Control of T2DM after LSG57. As a result, long-term complications like
LSG is achieved, as in other bariatric opera- gastric erosion and infections are not seen after
tions, with the rapid excess weight loss. However, LSG57. However, the extended gastric resection
glycemic control without diabetic medication, performed during LSG has a significant impact
normalization of hemoglobin A1c and improve- on gastric acid secretion and motility. Many pa-
ment or even resolution of T2DM are seen early tients experience a series of gastrointestinal (GI)
after LSG45. A reason for the early improvement symptoms postprandial, like heartburn, epigas-
of T2DM after LSG is the notable low levels of tric pain, distress and dysphagia. Nevertheless,
ghrelin. Ghrelin not only suppresses appetite, but the impact of all these GI symptoms on QoL is
also has a diabetogenic effect46. Also, Shah et al47 limited58.
documented that the faster gastric emptying and
small bowel transit time observed after LSG have
an additive effect on the control of T2DM. How to Sleeve

Sleeve gastrectomy (SG) is essentially a bar-


Improvement in systematic diseases iatric procedure consisting of a left partial gas-
(comorbidities) trectomy of the fundus and the body in order to
create a long, tubular formation along the lesser
Apart from diabetes mellitus, LSG offers im- curvature of the stomach59. Although open SG
provement and even resolution for a series of has been used for high-risk patients in the past,
comorbidities48. Various studies report improve- nowadays LSG is considered a primary bariatric
ment or remission of hypertension, dyslipidemia, procedure60,61. Sleeve gastrectomy can be safely
obstructive sleep apnea and degenerative joint performed even with other minimally invasive
disease after LSG18,49. Weiner et al50 reported that surgical techniques like single access surgery or
hypertension either improved or resolved in 97% robotic surgery, with comparable results62-65. The
of the patients, whereas dyslipidemia improved preoperative management of the patients under-
in 77% of the cases. Long-term results present- going LSG does not differ from other laparoscop-
ed, show a resolution in hypertension in half of ic bariatric procedures. Therefore, preoperative
the patients undergoing LSG22, 23. Obstructive risk assessment and evaluation to exclude other
sleep apnea, commonly seen in morbidly obese causes of obesity should be performed in every
patients, can also be improved in 80% of patients patient.
after surgical intervention51. To date there is a lack of standardization
regarding the surgical technique of LSG, which
may affect the long-term outcome of the patients.
Improvement in quality of life (QoL) However, in 2012 the first international expert
panel consensus statement regarding the “best
Laparoscopic SG results in considerable im- practice guidelines” was published, based on the
provement in the quality of life (QoL) and psycho- experience of more than 12,000 cases of LSG61.
social functioning52-55. First and foremost, LSG is The first step of LSG is the identification of
a pill and food friendly bariatric operation. Pills the Crow’s foot, the pylorus and the antrum.
are generally well tolerated, as well as drugs like Following this, a window in the greater omentum
aspirin and NSAIDS. In addition, food tolerance is made, laterally of the antrum66. Most experts
is very good, especially in the long-term55,56. The agree that it is important to mobilize the fundus
majority of patients report high rates of satis- before transection and to resect the short gastric

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Sleeve gastrectomy, a review

the last staple firing61. Soricelli et al73 tried to ex-


plain the vascular anatomy of this area, because
one of the best supported theories of proximal
fistula formation is the vascular-ischemic theo-
ry72. A “critical area” of vascularization is created
at the angle of His and the resection on that area
could lead to an ischemic gastric remnant, with
an increased likelihood for a leak. Therefore, it
is important to avoid resection too close to the
esophagus and avoid creating a stenosis at the
level of the angular incisure71.
In order to maintain a standardized gastric vol-
ume and allow the reproducibility of the technique
between different bariatric surgical teams a bougie
is used during the gastric division to facilitate the
resection. However, the size of the bougie is not
Figure 2. Surgical technique of LSG, showing how the size
standard and various sizes have been used from
of the final gastric pouch changes in regard to the usage of different bariatric surgeons. The bougie size is
different bougie sizes and different starting and ending tran- measured in French (Fr) where 1 Fr equals 0.33
section points. mm. This means that a 36 Fr bougie equals 1.2 cm
and a 40 Fr equals to 1.3 cm. Most surgeons use
a bougie between 32-40 Fr and, considering the
vessels before stomach division. This will assist above, we can safely assume that they practically
the creation of a small gastric pouch and allow use the same bougie size61,74. Small size bougies
the identification of any hiatal hernia61. If a hiatal have been associated with a higher incidence of
hernia is present, it should be repaired at the same staple line leaks, longer hospital stay, tendency
time by posterior crural approximation19. toward increased nausea, more emergency depart-
One of the most controversial points in LSG is ment visits, and readmissions74-77. Using bigger
the distance from the pylorus at which the gastric than 40 Fr bougies, reduces the relative risk for
division should begin. The aim of the surgeon is a leak up to 66%74,75. As a matter of fact, bigger
to perform a restrictive bariatric operation, with bougies result in larger gastric pouches and this
improved gastric emptying and decreased intralu- may affect the long-term weight loss. However,
minal pressure, in order to avoid a leak. The 2012 several studies have shown that using bougies
expert panel agreed that the transection should larger or equal to 40 Fr does not impact %EWL, at
begin 2-6 cm from the pylorus61. Although most least for the first three years postoperatively75,77,78.
authors start the resection at these distances, there In addition, different surgeons resect the stomach
are some that prefer the limits. Baltasar et al67 and at a different distance in respect to the bougie.
Mognol et al68 begin their resection at 2 cm from Some prefer to be very close to the bougie, while
the pylorus in order to create a very small gastric others keep a small distance, in order to perform
pouch, since LSG is mainly a restrictive bariatric a subsequent reinforcement of the staple line with
procedure. Others, like Givon-Madhala et al69 invaginating sutures72.
and Silecchia et al70 begin their division at 6-8 The experts seem to agree that staple line re-
cm from the pylorus, thus, preserving the gastric inforcement may reduce bleeding along the staple
antrum and its contractile function. However, the line, although many authors do not routinely per-
bariatric surgeon should always consider the fact form this reinforcement61, 79. Another reason for
that a smaller gastric pouch with intact gastric reinforcing the staple line is the control of postop-
antrum, leads to increased intraluminal pressures erative leaks. Fistulas on the staple line may be of
and gastric emptying difficulties, that could place mechanical-tissular cause, when the intraluminal
patients at higher risk for leaks and proximal fis- pressure exceeds the staple line strength, or of
tula formation at the gastroesophageal junction71. ischemic cause, as proposed in the vascular-isch-
Furthermore, another controversy in LSG is emic theory. Ischemic leaks typically occur on
where to end the gastric division. It seems that the fifth or sixth postoperative day, during the
most experts agree on the importance to stay inflammatory-proliferation phase of wound heal-
away from the gastroesophageal junction during ing. Respectively, if the cause is mechanical-tis-

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I. Kehagias, A. Zygomalas, D. Karavias, S. Karamanakos

sular, leaks present early on the first two postop- tients, before a prospective second-stage bariatric
erative days80. Based on this fact, some surgeons procedure (mainly RYGB) is performed, within
have adapted their technique, in order to reduce two years18.
the risk of a mechanical failure of the stapling It is important that all patients undergo com-
line. A number of different reinforcing materials prehensive interdisciplinary assessment by a team
have been introduced and many studies have tried of specialists experienced in obesity manage-
to provide evidence for their use81-84. Yet, staple ment and bariatric surgery. Sleeve gastrectomy
line invagination with a simple running sero-se- candidates should undergo routine preoperative
rous suture, with or without the addition of an assessment, like any other major abdominal sur-
omental patch, could efficiently control bleeding gery. Laparoscopic SG adheres to the indications
and attempt to reduce postoperative leaks without and guidelines of all other bariatric procedures94.
increasing the cost67,72,85. Choi et al86 and Glaysher Therefore, it should be offered to morbidly obese
et al87 have published important meta-analyses patients with metabolic syndrome and to patients
and review studies in order to answer the critical with a BMI of 35 kg/m2 and associated co-mor-
question of staple line reinforcement. However, bidities61,94.
while current evidence suggests that staple-line Super obese patients, with BMI > 50 kg/m2,
reinforcement may reduce the incidence of post- can be offered LSG as this procedure seems to be
operative leaks and other associated complica- also effective for this group of patients95-97. How-
tions, it does not significantly reduce bleeding ever, super obese patients tend to regain weight
complications and cannot be recommended as a after the first 12 months of follow-up, while main-
standard technique61,86. taining the improvement in co-morbidities98,99.
In order to identify potential leaks or defect Considering the above some authors believe that
sites of the staple line, many surgeons test the LSG should be the first step of a 2-step procedure
integrity of the newly-formed gastric pouch by for the management of super obese patients9,61.
introducing air or methylene blue at the end of the Laparoscopic SG seems to be a feasible and
operation. Nevertheless, a negative test does not safe procedure for high-risk surgical patients. It
exclude a postoperative leak and many authors can be used as a safe first surgical procedure in
do not perform these tests at all88,89. A simpler order to achieve rapid weight loss in high-risk pa-
test to discover a potential staple line defect is tients who need to undergo a second non-bariatric
to inflate the resected stomach with air using a procedure such as knee replacement, nephrec-
regular syringe89. tomy or spine surgery100. Chaudhry et al101 and
Some authors have proposed that the measure- Tariq et al102 have also published promising data
ment of the resected gastric volume at the end regarding morbidly obese patients with end-stage
of the procedure can safely predict the overall organ failure who successfully underwent LSG.
%EWL. A resected gastric volume of more than Laparoscopic SG has proved to be technically
500-1100 ml has been associated with %EWL feasible and effective in obese patients awaiting
of ≥ 50%50,90. However, the resected gastric vol- kidney transplantation, for adequate pre-trans-
ume is greater in patients with high preoperative plantation weight loss, thus improving their ac-
BMI91. Finally, it is important to send for routine cess to transplantation103. Sleeve gastrectomy can
histological examination all gastric specimens. be also used as a post-transplantation bariatric
In about 8% of the cases unanticipated findings procedure in kidney recipients, because by re-
warranting further clinical follow-up may be re- taining the intestinal continuity the uptake of im-
vealed, like H. pylori gastritis, autoimmune gas- munosuppressants is not disturbed104. Obese com-
tritis with a microcarcinoid formation, intestinal pensated cirrhotic patients can also tolerate LSG
metaplasia or even neoplasia92. well. Laparoscopic SG can be safely performed in
cirrhotic patients, with low risk for postoperative
complications, improving their metabolic syn-
Indications and contraindications drome and reducing hepatic steatosis105,106.
Inflammatory bowel disease (IBD) is con-
Laparoscopic SG should be considered a pri- sidered a contraindication for bariatric surgery.
mary bariatric procedure or the first stage of a However, in a study from Steed et al107 more
2-step approach for the management of morbidly than 18% of IBD population found to be obese.
obese patients18,59,61,93. In the later, LSG has been Furthermore, overexpessed obesity-related cyto-
used to treat initially super obese or high-risk pa- kines play a significant role in the development

4934
Sleeve gastrectomy, a review

of IBD108. Laparoscopic SG found to be safe and Complications and their


effective for the management of obese patients management
with IBD78,109,110.
Regarding the age of the patients LSG there are Laparoscopic sleeve gastrectomy has been
many studies that have published positive results considered to be a technically simple bariatric
for pediatric, adolescent and geriatric patients who procedure with acceptable weight loss, resolution
underwent LSG. Alqahtani et al111 reported their of comorbidities and low postoperative complica-
experience with LSG in children and adolescents tions. Compared to laparoscopic gastric bypass
(5-21 years of age) with a follow-up of 24 months and biliopancreatic diversion, LSG is easier to
with very promising results. They reported no perform and thus involves less risk. However, its
serious postoperative complications, resolution of complications can be more severe than those of
co-morbidities and acceptable %EWL. However, other bariatric surgical techniques72. The compli-
it is impossible at this time to estimate the overall cation rates after LSG vary among studies from
long-term consequences. Therefore, these patients 0% to 18%, with a 30-day postoperative mortality
should be managed in bariatric centers of excel- ranging from 0%-0.4%118-120. The postoperative
lence that offer all available surgical options and a complications can be distinguished in early and
strict long-term follow-up112. late.
Morbid obesity in elderly patients is a substan- Early complications generally involve bleed-
tial health problem. Perioperative management ing, gastric leak, obstruction, abscess formation,
of medical complications is crucial. Qin et al113 wound infection as well as all the other possible
in their recent multi-institutional study showed postoperative complications of major laparoscop-
that LSG may be a preferable option for elderly ic surgical procedures27. Late complications spe-
patients. Furthermore, LSG can be safely per- cific to LSG are the development of a fistula,
formed in elderly patients, with low long-term GERD, stenosis, neofundus, spiral sleeve and
reoperation and readmission risk. The periop- intathoracic sleeve migration, weight loss failure
erative risk of LSG in this patient population is and nutritional deficits37,72.
predominantly associated with the anticipated The most common and major early complica-
morbidity of advanced age113. Other studies have tion is certainly the postoperative bleeding which
also confirmed the safety and effectiveness of can occur in up to 16% of patients with a reported
LSG in the geriatric population114-116. average of 3.6%120-122. Usually, it occurs during
Other indications may include cases that the the first or second postoperative day and general-
small bowel is inaccessible due to adhesions from ly originates from the stapling line or the divided
prior operations and patients in whom repeated gastroepiploic vessels. Other sources of bleeding
endoscopy of the duodenum is necessary110. include trocar site, splenic injury or liver lacera-
The only absolute contraindication for per- tion119. Intraluminal bleeding has been reported
forming LSG is Barrett’s esophagus. The pro- to occur in 2% of cases19. Reinforcing the staple
gression from erosive reflux disease to Barrett’s line seems to be associated with a decreased risk
esophagus and gastric and esophageal cancer is of staple line hemorrhage86,123. In addition, in a
well established19, 61. Yet, the preoperative pres- recent randomized trial, Sroka et al124 proposed
ence of gastroesophageal reflux disease (GERD) routine elevation of the systolic blood pressure to
is only a relative contraindication, mainly due 140mmHg before termination of the procedure
to the fact that reflux symptoms may worsen in order to identify possible bleeding sites. The
after LSG22, 28, 61. The long-term effect of LSG treatment can be conservative, with blood trans-
in GERD is controversial. Chiu et al117 in their fusion and patient resuscitation, but there are
systematic review concluded that there is not cases for which reoperation is necessary for the
enough evidence to consolidate to a consensus definite control of the bleeding119.
regarding the effects of LSG on GERD. From the The gastric leak is a serious complication
studies they reviewed, some showed an increase of LSG with an incidence ranging from 0% to
in the incidence of GERD, while other reported 3.7%61,72,77. Proximal staple line leaks are more
a decrease. Himpens et al28 reported a biphasic common than distal ones59. The basic concept
pattern of GERD after LSG. Reflux symptoms is that a leak happens when the intralumi-
initially present in the first postoperative year, nal pressure exceeds the staple line or tissular
they gradually improve and reappear after the strength125. This situation usually occurs when
sixth year postoperatively. local factors like poor blood supply, stapling

4935
I. Kehagias, A. Zygomalas, D. Karavias, S. Karamanakos

issues or infection acutely impair the gastric tion with or without CT-guided percutaneous
wall healing72. In order to avoid leaks, tissues drainage of the abscess131. Endoscopic stenting
should be handled carefully and devices like after percutaneous drainage of an abscess is a
staples, electrocautery or other surgical equip- valid treatment option for a proximal leak61,128,131.
ment should be used rationally72,126. A number The endoscopic use of fibrin glues, plugs or clips
of studies investigated the use of staple line has also been reported, although their efficacy
reinforcing materials81-84. Recent studies suggest is not proven72,131. The surgeon should wait for
that staple-line reinforcement may reduce the in- at least 12 weeks with conservative therapy be-
cidence of postoperative leaks86,87. Nevertheless, fore considering a reoperation to address a leak.
a running sero-serous suture that invaginates Revision of the procedure and conversion to
the staple line from the angle of Hiss to the another operation are possible options61. In the
midpoint of the transection, and a second con- case of a re-intervention, conversion to gastric
tinuous suture from this point to the end, with bypass, Roux-en-Y, or total gastrectomy can be
or without an omental patch may be adequate in performed61,132,133.
order to reduce leak rate67,72,85. During stappling, The development of GERD or the worsening
it is also very important to compress the gastric of reflux symptoms has been reported by some
tissue carefully for a prolonged time (e.g. 30 sec) authors as a late complication of LSG. Kehagias
before firing in order to reduce tissue edema127. et al22 and Himpens et al28 reported a peak of
Additionally, a nasogastric tube can be left in GERD symptoms in the first year which de-
the newly-formed gastric pouch for 24 hours to clined during the first triennium. Himpens et al28
reduce intraluminal gastric pressure128. observed a second peak after the sixth year28.
Many authors routinely perform upper gas- The intact pylorus, the removal of the antrum,
trointestinal swallow studies postoperatively in the severely restricted gastric capacity and the
order to evaluate the presence of an early leak, disrupted motility could create stasis and induce
between the first and third postoperative day. or exacerbate reflux symptoms119. When the re-
However, the sensitivity of these studies is low section is not close enough to the esophagus, a
and a negative test does not exclude the pres- neofundus could form, which could also aggra-
ence of a leak126,128-130. Although gastric leaks vate the reflux symptoms due to increased gastric
can be accurately diagnosed with computed to- acid production119. Additionally, the presence of
mography, CT scans should only be performed a neofundus could also deteriorate GERD when
when the clinical suspicion is high and not for it is migrated intrathoracically, especially in the
screening129,130. If a leak occurs, the management presence of an untreated hiatal hernia. However,
is crucial for the outcome. The clinical presen- several studies have shown that the relationship
tation can vary greatly between patients and between GERD and LSG is multifactorial. Such
while most patients are completely asymptom- factors are an alteration of the lower esophageal
atic, complications like peritonitis, septic shock, sphincter pressure, reduction of gastric compli-
multi organ failure and death have been reported. ance and emptying, increased sleeve pressure,
Burgos et al126 observed that tachycardia can accelerated gastric emptying and the effect of
be the initial sign of a leak. Patients with he- weight loss117,134. Although GERD is considered
modynamic instability or those who cannot be a relative contraindication for LSG, some mod-
controlled using conservative measures require ifications have been proposed to address this
intervention. Postoperative leaks can be catego- problem. Identification of a hiatal hernia intra-
rized into acute (within 7 days), early (within 1-6 operatively should be persistent and if found, it
weeks), late (after 6 weeks) and chronic (after 12 should be repaired61. This can effectively control
weeks) in regard to the time of presentation61. the reflux symptoms135. An antireflux sleeve gas-
An acute fistula can be repaired surgically if the troplasty consisting of a combination of vertical
defect can be identified126. However, primary gastroplasty and Nissen fundoplication has been
repair of a fistula is associated with high rates proposed by Fedenko and Evdoshenko with en-
of recurrence. In late fistulas simple primary couraging results136. However, if reflux symptoms
repair of the defect is not possible due to chron- occur, proton pump inhibitors should be the first
ic inflammation and concomitant presence of line of treatment61.
an abscess128. Stable patients can benefit from Gastric stenosis and strictures following LSG,
conservative treatment, like nothing by mouth, although uncommon, can occur especially after
intravenous antibiotics and total parental nutri- some time137,138. Stenoses occur either distally,

4936
Sleeve gastrectomy, a review

when the transection is started close to the pylo- References


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