Obesity is a common disease affecting more than 300 million adults worldwide. It is defined as a body mass index greater than 30. Current options for bariatric surgery are categorized by several principles. Purely restrictive procedures include laparoscopic adjustable gastric banding and sleeve gastrectomy. Roux-en-Y gastric bypass is a restrictive surgery with a minor malabsorption approach. Largely malabsorptive procedures with a restrictive component include duodenal switch and biliopancreatic diversion.
The laparoscopic sleeve gastrectomy (LSG), also known as vertical gastrectomy, is a relatively new and effective surgical option for the management of morbid obesity which is gaining widespread popularity amongst patients and surgeons. Basically the stomach is dissected through keyhole surgery, they remove the fundus and greater curve of the stomach leaving a narrow tube of stomach resembling a sleeve which is where they derived the name of the operation.
The sleeve gastrectomy was first performed laparoscopically by Ren and colleagues in 1999. Initially the LSG was considered a first-stage operation in high-risk patients before the more complex operations like the Roux-en-Y gastric bypass. Laparoscopic sleeve gastrectomy was subsequently found to be effective as a single procedure for the treatment of morbid obesity. Although LSG functions as a restrictive procedure, it may also cause early satiety by removing the ghrelin-producing portion of the stomach.
For many patients considering weight loss surgery the end point is to focus on the excess weight loss but there are complications associated with the surgery which patients need to be aware of in their decision making process.
Haemorrhage: The risk of postoperative bleeding has been reported to be between 1% and 6% after LSG. . Common sources for bleeding include the gastric staple line, spleen, liver or abdominal wall at the sites of port entry.
Staple line leak: Gastric leak is one of the most serious and dreaded complications of LSG . It occurs in up to 5% of patients following LSG. Diabetes mellitus and sleep apnea were associated with a greater incidence of anastomotic leak.
Abscess: Intra-abdominal abscess is another possible complication after LSG. It usually presents with symptoms of abdominal pain, fever/chills or nausea and vomiting. In a series of 164 patients undergoing LSG, Lalor and colleagues reported 1 patient with an abscess (0.7%). Treatment includes percutaneous drainage and antibiotics.
Stricture: Formation of stricture is another potential complication occurring after LSG. It could present either acutely after surgery due to swollen tissue or more commonly in a delayed fashion. Presenting symptoms include food intolerance, dysphagia or nausea and vomiting. Diagnosis is an upper gastrointestinal study or endoscopy. Treatment options depend on the time of presentation. A stricture diagnosed acutely after surgery can sometimes be treated conservatively with bowel rest (nothing by mouth), rehydration with intravenous fluids and close observation. In the absence of other pathologies (e.g., abscess, leak), these strictures will spontaneously resolve with no need for further intervention. In contrast, chronic strictures usually require further intervention. These include either endoscopic or surgical treatments.
Nutritional deficiencies are common after bariatric surgery. This is multifactorial owing to impaired absorption and decreased oral intake. In a recent study by Gehrer and colleagues the prevalence of vitamin B12, vitamin D, folate, iron and zinc deficiency were reported to be 3%, 23%, 3%, 3% and 14%, respectively, after LSG. In general, these investigators found micronutrient deficiencies to be less prevalent after LSG than Roux-en-Y gastric bypass; however, folate deficiency was slightly more common after LSG than Roux-en-Y gastric bypass (22% v. 12%). 27 Routine blood work is therefore warranted after LSG to diagnose vitamin and mineral deficiencies.
Gastroesophageal Reflux Disease
Gastroesophageal reflux disease (GERD) is a condition seen commonly in the bariatric surgery population. Although some operations, such as Roux-en-Y gastric bypass, are known to be associated with a reduced incidence of reflux postoperatively, this is controversial for LSG. The most common reported symptoms included heartburn and regurgitation. Management of patients with persistent GERD involves treatment with proton pump inhibitors.
CONCLUSION: Laparoscopic sleeve gastrectomy is a new and effective procedure for the surgical management of morbid obesity. Therefore, the number of patients undergoing this procedure will continue to rise. Basic understanding of common complications is important for patients to make an informed decision with their surgeon.
Title: Complications associated with laparoscopic sleeve gastrectomy for morbid obesity: a surgeon’s guide
Authors: Kourosh Sarkhosh, MD, MSc* Daniel W. Birch, MD, MSc* Arya Sharma, MD, PhD, DSc Shahzeer Karmali, BSc, MD*
Ref: DOI: 10.1503/cjs.033511
J can chir, Vol. 56, No 5, octobre 2013