Anatomy - Laparoscopic sleeve gastrectomy - general and visceral surgery

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  • Introduction

    The incidence and prevalence of morbid obesity and its associated comorbidities is increasing worldwide, particularly in Western countries. According to the WHO, 600 million people worldwide are obese (BMI > 30 kg/m2).

    As evidenced by high-quality data, bariatric and metabolic surgical procedures are the most effective and long-lasting treatment modalities in morbid obesity and outperform nonsurgical multimodal regimens. 

    In addition to achieving sustained weight loss, surgery can also successfully treat obesity-related comorbidities, such as type 2 diabetes mellitus (T2DM); sleep apnea and other disorders of ventilatory control; obesity-related cardiomyopathy and hypertension; hyperlipidemia; pseudotumor cerebri; orthopedic damage to the knees; spinal problems; stress incontinence; polycystic ovary syndrome; and infertility. It is scientifically proven that massive weight reduction prevents or results in relative improvement or even remission of obesity-associated somatic diseases.

    The proliferation and acceptance of bariatric surgery has increased significantly worldwide over the past 20 years (approx. 150,000 procedures in 2003, 470,000 in 2013).

    The main pathophysiological mechanisms are restriction, malabsorption, and the combination of both.

    Hormonal effects play an important role in all procedures eliminating food from the gastroduodenal passage and/or resecting gastric volume. As 80% of ghrelin receptors (hunger hormone) are located in the stomach, elimination/resection will result in less hunger signaling to the brain.

    The large number of complex changes with metabolic effects unfolding in the enterohumoral axis because of surgery go well beyond weight loss.  

    The new term “metabolic surgery” reflects this expanded indication. Bariatric surgery is expected to play an increasingly important role in the management of metabolic syndrome.

    Many patients with T2DM undergo complete remission already within days of surgery and long before significant weight loss. The current discussion has evolved to the issue of treating normal weight and slightly overweight diabetics by metabolic surgery as well.

    With the advent of laparoscopic surgical techniques, these procedures, initially regarded as high-risk surgery, can now be performed with an acceptable risk profile.

    Bariatric and metabolic surgery is not covered by the Standard Benefits Catalog of the German Statutory Health Insurance providers. Therefore, each patient must apply individually to his/her provider for this type of surgery. 

  • Sleeve gastrectomy (SG)

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    Initially, SG was the first step in the two-stage biliopancreatic diversion with duodenal switch (BPD/DS). A large number of patients experienced relevant improvements in weight loss and their comorbidities after sleeve gastrectomy alone, thus prompting the development of sleeve gastrectomy as a stand-alone surgical procedure.

    Since 2014, SG has become the most common bariatric operation performed worldwide. 

    In sleeve gastrectomy, a narrow tube is formed along the small curvature, thereby not only restricting food intake, but also resulting in complex hormonal changes.

    Compared to gastric bypass surgery, SG benefits from less perioperative morbidity.

    There is no malabsorption and deficiency symptoms are less common than with the bypass procedures.

    Preserving the pylorus reduces the risk of dumping syndrome.

    Drawbacks include the irreversibility of the procedure, the rather high fistula rate, and the poorer remission rate in T2DM compared to bypass procedures.

    In patients with extreme obesity (BMI > 50 kg/m²) and/or massive comorbidities, a "staged approach" may be considered. Obese patients first undergo sleeve gastrectomy to initially lose some weight and, in a second operation, e.g., duodenal switch is performed for more effective weight loss. Conversion to gastric bypass is also an option.

    The mortality risk can be reduced from 6% to 1% by dividing this operation into two separate procedures.

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