Phẫu Thuật Giảm Béo (Bariatric Surgery)

Hyperoxaluria and nephrolithiasis have been reported following
Roux-en-Y gastric bypass surgery.91
After laparoscopic Roux-en-Y gastric bypass, vitamin D deficiency
and hyperparathyroidism commonly occur. Body mass index and Roux
limb length are not associated with these two conditions, but racial
differences do exist. There is a weak inverse correlation between
vitamin D and parathyroid hormone (PTH). Further research is needed
to elucidate the causes, treatments, and significance of hyperparathy-
roidism after LGB.93
Weight Evolution After RYGB
Weight loss after RYGB
Weight loss following gastric bypass surgery has been studied extensively.
Favourable results are published in short-term as well as long-term
follow-up studies.
Mean EWL after open RYGB ranges from 57 to 65 per cent at one
year.94 Schauer et al. found that EWL following laparoscopic RYGB was
68 per cent at one year and 83 per cent at two years.95 In a meta-analysis,
Buchwald et al. found that patients lose between 56.7 and 66.5 per cent
excess weight within the first 24 months after gastric bypass.35
In the SOS study, RYGB produced the greatest long-term weight
loss (25 per cent ± 11 per cent), followed by vertical banded gastroplasty
(16.5 per cent ± 11 per cent) and fixed or variable banding procedures
(13.2 per cent ± 13 per cent).96 Fobi et al., using the transected banded
gastric bypass followed 22 of 51 patients for ten years and reported a
mean of 72 per cent excess weight loss.97
The stability of the postoperative weight after RYGB was clearly
demonstrated by Pories et al.32 Their study of 608 patients with a
97 per cent follow-up showed a 58 per cent loss of excess weight after
five years and a BMI of 33.7. After ten years, the excess weight loss was
55 per cent and the BMI was 34.7 (range, 22.5–64.7). At 14 years (ten
patients), the EWL was 49 per cent and the BMI 34.9 (range,
25.9–54.6).
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183

Insufficient weight loss or weight regain after RYGB
The course of excess weight loss after bariatric surgery continues to be a
subject of investigation. Bariatric surgeons recognize that a certain weight
regain occurs after obesity surgery compared to the lowest weight
observed between 18 and 24 months after surgery, a period characterized
by higher excess weight loss. Apparently, this regain mainly occurs
between two and five years after gastric bypass.98
Brolin et al. reported a 33 per cent failure rate in super-obese
patients seven years after surgery.99 Capella et al. demonstrated an aver-
age excess weight loss of 77 per cent and failure because of excess
weight loss less than 50 per cent in 7 per cent of the patients after
five years of follow-up.100 MacLean et al. demonstrated an excess
weight loss less than 50 per cent in 7 per cent of morbidly obese patients
over three years of follow-up and in 43 per cent of super-obese
patients.101
Weight regain after RYGB can be due to increased volume intake
from gastric pouch dilation, gastrojejunostomy dilation or presence of
gastro-gastric fistulas.
It can also be caused by an inadequate length of the alimentary limb
resulting in reduced malabsorption, and by changes in eating behaviour
such as sweet-eating, grazing or polyphagia and volume eating or
hyperphagia.
Gastric pouch dilatation or dilatation of the gastrojejunostomy can be
treated with endoluminal techniques such as StomaphyX™and
Endocinch™. In the case of weight regain caused by volume eating or
hyperphagia, a possible treatment can be offered by surgical revision
aiming at restoring restriction. Additional restriction can be obtained by
placing an adjustable or non-adjustable band around the gastric pouch
(Fig. 13).102,103 Lengthening of the alimentary limb by conversion to distal
RYGB seems to result in unacceptable malnutrition.
Change of the patient’s alimentary behaviour remains an extremely
difficult aspect. Some patients start eating sweets because they are no
longer affected by the dumping syndrome; others become grazers by
eating too frequently (polyphagia). Due to these dietary flaws, patients
can increase their caloric uptake and consequently gain weight.104
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Resolution of co-morbidities after RYGB
Morbidly obese patients have been identified as being at high risk for the
metabolic syndrome comprising a combination of hypertension, dyslipi-
demia, glucose intolerance and obesity. If left untreated, the progression
to cardiovascular disease has been documented in these patients. Weight
loss is critical to the treatment of this condition, and one year postopera-
tively metabolic syndrome can be reversed in up to 98 per cent of
patients.105
Diabetes, hypertension, hypercholesterolemia, and obstructive sleep
apnoea are among the commonly reported co-morbid conditions which
tend to improve significantly or resolve completely following RYGB.
A meta-analysis of more than 136 studies, totalling more than 22,000
patients, was undertaken by Buchwald et al. Diabetes mellitus and glu-
cose intolerance demonstrated concomitant improvement in haemoglobin
A1C levels and fasting glucose in 83 per cent of affected patients.
Hypertension resolved completely in 67.5 per cent of affected patients and
Roux-en-Y Gastric Bypass
185
Figure 13.
Adjustable banded gastric bypass (picture after Dr B. Dillemans).

improved in up to 87 per cent. Similarly, hyperlipidemia (96.9 per cent
improvement), obstructive sleep apnoea (94.8 per cent resolution or
improvement), gastroesophageal reflux disease, pseudotumor cerebri, uri-
nary stress incontinence, and other co-morbid conditions demonstrated
variable, but positive, response to RYGB.35 In the chapter on the effect of
bariatric surgery on co-morbidities all these conditions are discussed
separately and more in detail.
Health-related quality of life
Because morbid obesity has a negative impact on health-related quality of
life (HRQoL),106 the ultimate goal of bariatric surgery is improved
HRQoL through adequate weight loss and cure or amelioration of co-
morbidities. As a consequence, divergent dimensions of quality of life
(QoL) have been widely accepted as important health outcomes after
surgical intervention.107,108
In general, QoL substantially improves following bariatric surgery,109
especially within the first two postoperative years,110 but also after long
follow-up duration,111 and even within six months112 or as soon as two to
three weeks after surgery.113 Most studies suggest that HRQoL normalizes
following bariatric surgery,113,114 but according to others, improvements
lag behind HRQoL of reference groups.109 This may not be surprising,
given that most patients are still obese.
QoL seems to be closely related to the patient’s level of satisfaction
with the results of the operation.106,115,116 Most patients report satisfac-
tion with the surgery, with some studies reporting >90 per cent
satisfaction rates.106,116 However, after some time a slight decline may
occur, which can be explained by the slow-down of weight reduction or
the occurrence of first complications.117 It is important to note that up
to 20 per cent of patients are dissatisfied, partly due to psychosocial
problems, surgical complications and the surgery not meeting their
expectations.111,118
However, almost all patients say they would undergo the operation
again;119 they appear to achieve most of their goals, even though not all of
them obtain their desired weight loss.120
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Hell et al. conducted a trial to compare the effects and outcomes of
three different bariatric procedures: RYGB, VBG and AGB. In this
prospective comparative study with 30 matched patients from each group,
patients were followed to assess post-operative improvement in health
status and quality of life, to compare the three different techniques. The
Bariatric Analysis and Reporting Outcome System (BAROS) as described
by Oria and Moorehead121 has been used for evaluation.
The observation time was at least three years (three to eight years) in
each individual case. A significant increase in quality of life and health
status in 75 per cent of the surgically-treated patients was observed when
compared with a non-operated control group of morbidly obese patients.
By utilizing BAROS it has been found possible to compare the results of
different procedures done by different surgeons with different techniques,
utilizing patients from different cultures and with different languages. The
results of this comparative study favour the standard gastric bypass for the
treatment of morbid obesity. This operation is superior to purely gastric
restrictive procedures in weight loss and improvement of quality of life.122
Long-term mortality after RYGB
Adams et al. examined the records of patients who had undergone gastric
bypass surgery to determine their long-term risk of death, as compared
with that of a population control group inwhich weight was self-reported.
In this retrospective cohort study, the authors determined the long-term
mortality among 9,949 patientswho had undergone gastric bypass surgery
and 9,628 severely obese persons who applied for driver’s licences. From
these subjects, 7,925 surgical patients and 7,925 severely obese control
subjects were matched for age, sex and body-mass index. They deter-
mined the rates of death from any cause and from specific causes with the
use of the National Death Index. During a mean follow-up of 7.1 years,
adjusted long-term mortality from any cause in the surgery group
decreased by 40 per cent,as compared with that in the control group (37.6
versus 57.1 deaths per 10,000 person-years, P < 0.001); cause-specific
mortalityin the surgery group decreased by 56 per cent for coronary artery
disease(2.6 versus 5.9 per 10,000 person-years, P = 0.006), by 92 per cent
for diabetes (0.4 versus 3.4 per 10,000 person-years, P = 0.005) and by
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187

60 per cent for cancer (5.5 versus 13.3 per 10,000 person-years, P <
0.001). However, rates of death not caused by disease, such as accidents
and suicide, were 58 per cent higher in the surgery group than in the con-
trol group (11.1 versus 6.4 per 10,000 person-years, P = 0.04). Despite
certain limitations, these findings indicate that patients who undergo gas-
tric bypass surgery have decreased long-term mortality from any cause
and from disease-specific causes but have increased mortality from non-
disease causes, as compared with control subjects. The study provides
useful data for patients considering gastric bypass surgery, for medical
professionalsserving the severely obese population, and for insurance car-
riers making decisions about whether to cover this procedure.123
Conclusion
RYGB is nowadays considered as the ‘gold standard’ surgical weight loss
procedure. It not only results in excellent weight loss, but also resolves or
improves associated co-morbidities such as type 2 diabetes. Moreover,
quality of life after RYGB seems to be superior to the restrictive type of
bariatric procedures.
Acknowledgements
We would like to thank Dr. Girish Bapat for his contribution to the review
of the literature on RYGB.
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blind, randomized study. Arch Surg 133(7): 740–744.
86. Dalcanale, L., Oliveira, C.P., Faintuch, J. et al. (2009). Long-term nutri-
tional outcome after gastric bypass. Obes Surg 20(2): 181–187 (Epub 2009
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87. Hamoui, N., Anthone, G., Crookes, P.F. (2004). Calcium metabolism in the
morbidly obese. Obes Surg 14(1): 9–12.
88. DiGiorgi, M., Daud, A., Inabnet, W.B. et al. (2008). Markers of bone and
calcium metabolism following gastric bypass and laparoscopic adjustable
gastric banding. Obes Surg 18(9): 1144–1148.
89. Johnson, J.M., Maher, J.W., DeMaria, E.J. et al. (2006). The long-term effects
of gastric bypass on vitamin D metabolism. Ann Surg 243(5): 701–704.
90. Ybarra, J., Sanchez-Hernandez, J., Gich, I. et al. (2005). Unchanged
hypovitaminosis D and secondary hyperparathyroidism in morbid obesity
after bariatric surgery. Obes Surg 15(3): 330–335.
91. Youssef, Y., Richards, W.O., Sekhar, N. et al. (2007). Risk of secondary
hyperparathyroidism after laparoscopic gastric bypass surgery in obese
women. Surg Endosc 21(8): 1393–1396.
92. De Prisco, C., Levine, S.N. (2005). Metabolic bone disease after gastric
bypass surgery for obesity. Am J Med Sci 329(2): 57–61.
93. Clements, R.H., Yellumahanthi, K., Wesley, M.
et al. (2008).
Hyperparathyroidism and vitamin D deficiency after laparoscopic gastric
bypass. Am Surg 74(6): 469–474.
94. Perugini, R.A., Mason, R., Czerniach, D.R. et al. (2003). Predictors of
complication and suboptimal weight loss after laparoscopic Roux-en-Y
gastric bypass: a series of 188 patients. Arch Surg 138(5): 541–545; dis-
cussion 545–546.
95. Schauer, P., Ikramuddin, S., Hamad, G. et al. (2003). The learning curve for
laparoscopic Roux-en-Y gastric bypass is 100 cases. Surg Endosc 17(2):
212–215.
96. Sjostrom, L., Lindroos, A.K., Peltonen, M. et al. (2004). Lifestyle, diabetes,
and cardiovascular risk factors 10 years after bariatric surgery. N Engl J
Med 351(26): 2683–2693.
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97. Fobi, M.A., Lee, H., Felahy, B. et al. (2005). Choosing an operation for weight
control, and the transected banded gastric bypass. Obes Surg 15(1): 114–121.
98. Magro, D.O., Geloneze, B., Delfini, R. et al. (2008). Long-term weight
regain after gastric bypass: a 5-year prospective study. Obes Surg 18(6):
648–651.
99. Brolin, R.E., Kenler, H.A., Gorman, J.H. et al. (1992). Long-limb gastric
bypass in the superobese. A prospective randomized study. Ann Surg
215(4): 387–395.
100. Capella, J.F., Capella, R.F. (1996). The weight reduction operation of
choice: vertical banded gastroplasty or gastric bypass? Am J Surg 171(1):
74–79.
101. MacLean, L.D., Rhode, B.M., Nohr, C.W. (2000). Late outcome of isolated
gastric bypass. Ann Surg 231(4): 524–528.
102. Bessler, M., Daud, A., Digiorgi, M.F. et al. (2009). Adjustable gastric band-
ing as revisional bariatric procedure after failed gastric bypass-intermediate
results. Surg Obes Relat Dis 6(1): 31–35
103. Bessler, M., Daud, A., DiGiorgi, M.F. et al. (2005). Adjustable gastric
banding as a revisional bariatric procedure after failed gastric bypass. Obes
Surg 15(10): 1443–1448.
104. Dapri, G., Cadière, G.B., Himpens, J. (2009). Laparoscopic placement of
non-adjustable silicone ring for weight regain after Roux-en-Y gastric
bypass. Obes Surg 19(5): 650–654.
105. Sugerman, H.J., Wolfe, L.G., Sica, D.A. et al. (2003). Diabetes and hyper-
tension in severe obesity and effects of gastric bypass-induced weight loss.
Ann Surg 237(6): 751–756; discussion 757–758.
106. Mathus-Vliegen, E.M., de Weerd, S., de Wit, L.T. (2004). Health-related
quality-of-life in patients with morbid obesity after gastric banding for sur-
gically induced weight loss. Surgery 135(5): 489–497.
107. Guisado, J.A., Vaz, F.J. (2003). Personality profiles of the morbidly obese
after vertical banded gastroplasty. Obes Surg 13(3): 394–398.
108. Tolonen, P., Victorzon, M. (2003). Quality of life following laparoscopic
adjustable gastric banding — the Swedish band and the Moorehead-Ardelt
questionnaire. Obes Surg 13(3): 424–426.
109. Boan, J., Kolotkin, R.L., Westman, E.C. et al. (2004). Binge eating, quality
of life and physical activity improve after Roux-en-Y gastric bypass for
morbid obesity. Obes Surg 14(3): 341–348.
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110. Freys, S.M., Tigges, H., Heimbucher, J. et al. (2001). Quality of life fol-
lowing laparoscopic gastric banding in patients with morbid obesity.
J Gastrointest Surg 5(4): 401–407.
111. Shai, I., Henkin, Y., Weitzman, S. et al. (2003). Determinants of long-term
satisfaction after vertical banded gastroplasty. Obes Surg 13(2): 269–274.
112. Sabbioni, M.E., Dickson, M.H., Eychmuller, S. et al. (2002). Intermediate
results of health related quality of life after vertical banded gastroplasty. Int
J Obes Relat Metab Disord 26(2): 277–280.
113. Dymek, M.P., Le Grange, D., Neven, K. et al. (2002). Quality of life after
gastric bypass surgery: a cross-sectional study. Obes Res 10(11): 1135–1142.
114. Choban, P.S., Onyejekwe, J., Burge, J.C. et al. (1999). A health status
assessment of the impact of weight loss following Roux-en-Y gastric
bypass for clinically severe obesity. J Am Coll Surg 188(5): 491–497.
115. Wadden, T.A., Sarwer, D.B., Womble, L.G. et al. (2001). Psychosocial aspects
of obesity and obesity surgery. Surg Clin North Am 81(5): 1001–1024.
116. Kinzl, J.F., Traweger, C., Trefalt, E. et al. (2003). Psychosocial conse-
quences of weight loss following gastric banding for morbid obesity. Obes
Surg 13(1): 105–110.
117. Buddeberg-Fischer, B., Klaghofer, R., Sigrist, S. et al. (2004). Impact of
psychosocial stress and symptoms on indication for bariatric surgery and
outcome in morbidly obese patients. Obes Surg 14(3): 361–369.
118. Sannen, I., Himpens, J., Leman, G. (2001). Causes of dissatisfaction in
some patients after adjustable gastric banding. Obes Surg 11(5): 605–608.
119. Kriwanek, S., Blauensteiner, W., Lebisch, E. et al. (2000). Dietary changes
after vertical banded gastroplasty. Obes Surg 10(1): 37–40.
120. Foster, G.D., Wadden, T.A., Vogt, R.A. et al. (1997). What is a reasonable
weight loss? Patients’ expectations and evaluations of obesity treatment
outcomes. J Consult Clin Psychol 65(1): 79–85.
121. Oria, H.E., Moorehead, M.K. (1998). Bariatric analysis and reporting out-
come system (BAROS). Obes Surg 8(5): 487–499.
122. Hell, E., Miller, K.A., Moorehead, M.K. et al. (2000). Evaluation of health
status and quality of life after bariatric surgery: comparison of standard
Roux-en-Y gastric bypass, vertical banded gastroplasty and laparoscopic
adjustable silicone gastric banding. Obes Surg 10(3): 214–219.
123. Adams, T.D., Gress, R.E., Smith, S.C. et al. (2007). Long-term mortality
after gastric bypass surgery. N Engl J Med 357(8): 753–761.
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Chapter 8
New Technologies in Bariatric Surgery
Matthias Lannoo and Andre D’Hoore
Introduction
In this chapter on new technologies in bariatric surgery two main subjects
are addressed: sleeve gastrectomy and the new minimally invasive
approaches of single incision laparoscopic surgery (SILS) and natural
orifice transluminal endoscopic surgery (NOTES). There is increasing
interest in primary sleeve gastrectomy either as a primary procedure to
reduce morbidity related with duodenal switch procedures or as a ‘stand
alone’ restrictive procedure. Furthermore, sleeve gastrectomy is a model
for NOTES and SILS, both recent developments to further reduce the
extent of access trauma by using a single port access. In NOTES a natural
orifice is used to gain access to perform surgery and merges laparoscopic
and endoscopic techniques. Reducing the surgical trauma is of utmost
importance in the group of high-risk morbidly obese patients. Both
methods however need to be validated.
Sleeve Gastrectomy
Introduction
Bariatric surgical procedures reduce caloric intake by modifying the
anatomy of the gastrointestinal tract. These operations are classified as
either restrictive or malabsorptive. Restrictive procedures limit intake by
creating a small gastric reservoir with a narrow outlet to delay emptying
199

200
M. Lannoo and A. D’Hoore
and induce early satiety. Such procedures include the vertical banded gas-
troplasty (Mason) and the adjustable gastric banding.1 A vertical restrictive
sleeve gastrectomy (SG) is categorized as a restrictive operation: the volume
of the stomach is reduced by 90 per cent and only the non-compliant
smaller curvature part of the stomach is retained. The remainder of the
stomach loses its capability to extend during eating,2 and in contrast to
former restrictive procedures where the outlet is created using a permanent
ring, the outlet of the gastric sleeve is regulated by the pylorus.
After Gagner noticed the good results of the Mill and Magenstrasse
procedure invented by Johnston et al., he developed the SG as a first step
procedure in biliopancreatic diversion (BPD) to reduce mortality and
morbidity in super-obese patients.3,4 Results showed an excess body
weight reduction in the range of 45 per cent and amazingly not all patients
regained weight despite the absence of a outlet calibration. These findings
led to the strategy to propose SG as a primary procedure. Midterm follow-
up outcome data in primary GS resections indicate that it could indeed be
an effective procedure for a subgroup of morbidly obese patients. These
positive results of SG challenge the ‘mechanistic concept’that a calibrated
outlet is the key to success for a restrictive procedure. Outcome after SG
could be the result of neuro-humoral alterations influencing appetite con-
trol, early satiety and beneficial taste change. As a consequence SG could
be an interesting model to study metabolic changes in an attempt to
impact type II diabetes in the future.
History
SG was originally the restrictive part of a malabsorptive operation: the
biliopancreatic diversion–duodenal switch (BPD–DS). Hess performed
the first DS operation in March 19885,6 and Marceau et al. published the
first paper.7 In September 1999 Rabkin did the first hand-assisted laparo-
scopic DS (LDS),8 and Gagner et al. performed the first totally
laparoscopic DS (LDS).9 Gagner’s group published the concept of a two
stage approach with a laparoscopic SG (LSG) as the first stage of the LDS
in super-obese patients.4
LSG has been proposed as the first step in the treatment of super-
obese patients, or in patients with high operative risk, to induce significant

weight reduction and to reduce morbidity linked with the biliopancreatic
diversion procedure. This would precede more complicated procedures
such as laparoscopic BPD–DS or laparoscopic Roux-en-Y gastric bypass
(LRYGBP).10
Definition
Sleeve gastrectomy is a term for partial gastrectomy that results in removal
of most of the stomach, with the remainder resembling a ‘banana’ or ‘half
moon’ (Fig. 1). The other names for this procedure are ‘partial gastrec-
tomy’, ‘longitudinal gastrectomy’ and ‘vertical gastrectomy’. The pylorus
as natural outlet is the most important feature of this operation.
Technique
SG involves a longitudinal resection of the greater curvature of the
stomach from the antrum, starting opposite to the nerve of Latarjet, up to
the angle of His.11 This longitudinal gastrectomy ‘sleeves’ the stomach to
reduce it to a narrow tube and eliminates the gastric fundus, the dilating
New Technologies in Bariatric Surgery
201
Figure 1.
Sleeve gastrectomy, the greater curvature of the stomach is resected.

part of the stomach. A naso-gastric tube (bougie) is used to obtain a pre-
cise calibration and to avoid stenosis of the gastroplasty. There are
multiple technical variations. There is variation in the size of bougie that
calibrates the diameter of the sleeve. The size of the bougie used does not
seem to ultimately influence weight loss. Large bougies (50 Fr and more)
have been associated with ischemia and gastric fistula and small bougie
on the other hand could herald a risk of stenosis. Dissection at the angle
of His is critical to avoid the dreadful complication of iatrogenic stapling
on the oesophagus.
There seems some agreement now over the use of a 32–36 Fr tube,
which should be positioned along the smaller curvature. Stapling that is
too wide (incorporating part of the fundus) will ultimately result in sleeve
dilation on the long term. In addition, the distance to the pylorus where
stapling on the greater curvature starts is variable. It looks more attractive
to leave the antrum to regulate gastric emptying and to diminish the risk
of narrowing the sleeve at the incisura angularis. Dissection close to the
pylorus could eventually change antral motor activity and cross-stapling
could be hazardous due to tissue thickness.12 Leakage is most frequent at
the upper and middle part of the stomach as a result of oesophageal
trauma and/or high intraluminal pressure in this part of the sleeve due to
narrowing more distally. Air insufflation and/or methylene blue instilla-
tion has been proposed to control staple line integrity during surgery. A
gastrografin swallow in the early postoperative phase is highly advisable.
Staple line reinforcement using Seamgard® has been proposed; this seems
to significantly reduce postoperative bleeding events at the staple line and
only to have a limited effect on the risk for perforation.13,14 The data to use
this reinforcement consequently are lacking. The type of cartridge used to
perform the sleeve is of importance and indeed a staple that is too small
could induce leaks certainly at the distal part of the sleeve. There are not
enough data to advise a suturing over the staple line, which could have a
detrimental effect on tissue healing.
Results
Discussion of the results of SG is not easy due to the small numbers of
patients in most studies and the lack of standardization of procedures.
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M. Lannoo and A. D’Hoore

The main distinction we have to take into account is the possible dif-
ference in size of the sleeve: larger when it is part of the two-stage
concept of a BPD–DS operation and smaller when it is a primary
procedure.
Weight loss
It seems controversial to state that a procedure such as SG can induce a
long-term sustainable weight loss, as there is no outlet restriction. On the
other hand there has been no procedure until now where such an extensive
part of the stomach is resected reducing the capacity by almost 100 per
cent and virtually eliminating the production of the orexigenic hormone,
ghrelin. Some data on a recent series of primary SG procedures with a
follow-up of at least one year are presented in Table 1.
Ten studies have been selected. Most are observational cohort data
except for the studies of Himpens and Vidal, which are prospective, ran-
domized studies comparing the outcome of SG with LAGB and RYGB.
At one year a significant loss of >50 per cent in weight or BMI is observed
in most studies. No mortality was reported and major complications were
around 5 per cent. Although these are data on primary procedures,
patients’ demographics are still different from the series of patients that
undergo gastric bypass or gastric banding: higher preoperative BMI, older
patients and higher portion of males. The results of these excellent results
clearly favour the SG procedure.
It is important to mention a few studies separately as they specifi-
cally look at SG as a primary procedure. Meneakos has a series of 261
patients. At one year follow-up a median percentage EWL of 65.7 (range
33.8–102.3) is noted. The median BMI for the patients who had
completed at least one year of follow-up is 30.5 kg/m2 (range
21.2–42.7). The overall success rate after the first year for more than 50
per cent EWL is 74.3 per cent and even reaches 81.7 per cent with a BMI
<35 as a cut-off.25 The study of Jacobs and colleagues is most interest-
ing as they have a total of 40 patients with a follow-up at two years and
157 patients eligible for follow-up at one year. Mean percentage EWL,
for patients at one and two years are 78 per cent and 75 per cent respec-
tively. There is no significant difference between the use of 46 Fr, 40 Fr
New Technologies in Bariatric Surgery
203

204
M. Lannoo and A. D’Hoore
Table 1.
Sleeve gastrectomy complications and results.
Initial
Patients
BMI
EBL
EWL
Author
(n)
Sex
Mean age
(kg/m2)
Complications
Deaths
1 year (%)
1 year (%)
Himpens15
40
9M, 31F
40 (22–65)
39 (30–53)
Perioperative: 1
None
Not Addressed
57.7
bleeding (2.5%);
(N/A)
(0–125.5)
1 sleeve ischemia
(2.5%)
Postoperative:
2 gastric pain (5%);
1 frequent vomiting
(2.5%); 2 mineral
deficit (5%); 7 de novo
GORD (21.8%)
Karamanakos16
16
1M, 15F
30.6 (19–50)
45.1 (37–51)
None
None
N/A
69.7 ± 14.6
Nocca17
163
57M, 111F
41.57
45.9
Perioperative: 9 staple
None
N/A
49.45
line leaks (5.52%);
1 stapling of gastric
tube (0.61%); 1 liver
bleeding (0.61%)
Postoperative: 6 gastric
fistula (3.66%);
2 gastric stenosis
(1.22%); 1 bleeding
(0.66%) GORD 11.8%
(Continued)

New Technologies in Bariatric Surgery
205
Table 1.
(Continued )
Initial
Patients
BMI
EBL
EWL
Author
(n)
Sex
Mean age
(kg/m2)
Complications
Deaths
1 year (%)
1 year (%)
Ou Yang18
138
49M, 89F
NA
50.6 (33–82)
Perioperative overall:
None
N/A
54.5 ± 22.32
(1.4%); 2 leakage
(1.5%); 3 bleeding
(2.2%); 1 pancreatitis
(0.7%); 1 stricture 0.7%)
Fuks19
135
22M, 113F
40 (18–65)
48.8 (37–72)
Perioperative: 10
None
49.4
NA
bleeding (7.4%)
3 staple line leaks
(2.2%)
Postoperative:
7 gastric fistula (5.1%)
Uglioni20
70
16M, 54F
43 (21–65)
46 (35–61)
5% major 7% minor
None
65 (9–127)
NA
Rubin21
120
22M, 98F
38 ± 11.8
43 (30–63)
None
None
53 ± 24
NA
Vida22
39
16M, 23F
50 ± 1.5
51.9 ± 1.2
NA
None
63 ± 2.89
NA
Lee23
216
43M, 173F
43 ± 11
49 ± 11
2.3% readmissions
None
N/A
59 ± 17
2.8% reoperations
4.6% major
7.4% total
complications
Melissas24
23
7M, 16F
38.9 ± 11.9
47.2 ± 4.8
5.8% staple line leaks
None
72.5
NA
15.3% haemorrhage
0% reoperations

and 36 Fr bougie and no difference between the use of a 7 cm versus a
4 cm antral pouch.26
At the IFSO (International Federation for the Surgery of Obesity and
Metabolic Disorders) congress of 2009, Angrisani et al. reported on
698 patients with more than half of them receiving an SG as a primary
operation. The resulting percentage EWL at one, two and three years are
56 per cent, 43 per cent and 31 per cent respectively. These results are
comparable to those seen after RYGBP. Vidal et al. prospectively com-
pared SG with RYGB and found that 12 months after surgery, subjects
undergoing SG and RYGB lose a similar amount of weight (percentage
EBL: SG: 63.00 ± 2.89 per cent, RYGB: 66.06 ± 2.34 per cent).22
The report of the Spanish register on 540 patients by Carlos-Sanchez
et al. shows they conclude with a mean follow-up of 16.5 ± 10.6 months
(with a range of 1–73 months) and that LSG provides a mean percentage
EWL at 12 months of 63.83 (n = 281), at 24 months of 68.5 (n = 120), and
at 36 months of 67.12 (n = 30). They also decided after subanalysis for
bougie size, initial BMI and age (cut-off of 50 years) that better results are
obtained in younger patients with lowest BMI. Thinner bougies only give
better weight loss the first six months. Cut-off of 38 Fr for bougie size
analysis is perhaps a rather low to prove that dilatation over time is
inevitable with larger bougie size as used in the early sleeve gastrectomies
of 52–60 Fr. Sixty-eight per cent of the patients had a bougie of 32–34 Fr.27
When we look at the German registry at the results of their 144 SGs,
we see that although a bougie of 32 Fr is used there was only a reduction
of ten BMI points in comparison with the RYGBP patients who lost
16 BMI points. Mean preoperative BMI is of course significantly higher.28
In conclusion we can state that the weight loss after primary SG is
almost in the same range as after gastric bypass when care is taken to
resect the entire fundus of the stomach.16,29 A smaller bougie size is prob-
ably more suitable in achieving this goal. The weight loss will probably
be insufficient for super-obese patients and a second stage operation will
be necessary for this subpopulation. The possible mechanisms that
account for the limited weight loss or weight regain after SG include the
spontaneous dilation of the gastric tube over time or the switch to a high
caloric, soft, liquid diet.11 It is also important to mention the excellent food
tolerance in contrast with the other restrictive procedures.27
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Of course, long term data are needed to evaluate the potential danger
of weight regain, as no calibration outlet is present in this restrictive
procedure. In this context it is important to mention the five year follow-up
data of Johnston et al. who invented and validated the Mill and
Magenstrasse operation. This procedure consists of a similar gastric tube
as used in an SG without an outlet besides the pylorus, with the difference
that the greater curvature is not resected. This procedure achieves a
percentage EWL of 61 long term.3,23
Co-morbidities
It appears that SG catalogued as a restrictive procedure, could have more
potential than expected. Resolution of co-morbidities is on first sight is as
high as after gastric bypass procedures and higher than after the purely
restrictive procedures. Preliminary data suggest that it could also have a
very fast effect and so possibly partly independent of the weight loss.
Two large studies looked at the effect of SG on co-morbidities.
Cottam et al. describe resolution of type II diabetes in 81 per cent and
improvement in an additional 11 per cent of patients. Sleep apnoea is
improved or resolved in 87 per cent, hypertension in 85 per cent of the
patients. Remarkable too is a 70 per cent resolution of GORD after SG in
this large series.30
The series of Moon Han et al. are even more impressive with an
almost complete response of type II diabetes and sleep apnoea in sleeve
patients. Of course, the metabolic syndromes of Korean and Indian popu-
lations are very different from that of Caucasians.31,32
Rosenthal did a retrospective review of a prospectively maintained
database to investigate the effect of SG on type II diabetes patients. His
conclusion is that the effect of this procedure is fast, as 27 per cent of the
patients are already free of diabetes after two months and 63 per cent after
six months. The longer the disease exists and the lower the percentage
EWL after surgery means that the chances of total recovery will be
lower.33
Most interesting is the prospective randomized study done by Vidal
et al. on Type II diabetes mellitus and the metabolic syndrome following
sleeve gastrectomy in severely obese subjects between SG and RYGBP
New Technologies in Bariatric Surgery
207

regarding the effect on diabetes. They conclude that at 12 months after
surgery, SG is as effective as GBP in inducing remission of type II dia-
betes mellitus.
Recently Peterli et al. looked more into the standard meal induced
changes of the glucose metabolism. The almost comparable results showing
beneficial changes in glucose metabolism between gastric bypass patients
and SG patients at the earliest time point (one week postoperatively) sug-
gests that SG may possibly have an effect independent of weight loss.34
SG has more therapeutic potential than other restrictive procedures
and probably the same as an RYGBP. In the future SG will possibly be
part of the new procedures to treat the metabolic syndrome even in leaner
patients.
Complications
Short term
General complications such as pulmonary, cardiovascular and wound
problems are also possible after SG as in other operative procedures
in obese patients. The possible advantage of this procedure is a reduc-
tion in these complications due to a shorter operating time. The absence
of an anastomosis can influence the leakage rate positively. The long sta-
pler line can, on the other hand, neutralize this advantage.
Overall, the complication rate of SG published in the literature is
equivalent to Roux-en-Y gastric bypass for the greater part of a high-risk
population (see Table 1). Akkary et al. have been synthesising the litera-
ture and found that the incidence of complications among the selected
publications, including 646 patients who underwent SG were:
•
reoperation (4.5 per cent);
•
leak (0.9 per cent);
•
strictures (0.7 per cent);
•
postoperative bleeding (0.3 per cent);
•
pulmonary embolism (0.3 per cent);
•
delayed gastric emptying (0.3 per cent);
•
intra-abdominal abscess (0.1 per cent);
208
M. Lannoo and A. D’Hoore

•
wound infection (0.1 per cent);
•
splenic injury (0.1 per cent);
•
trocar site hernia (0.1 per cent).
Four mortalities were reported (0.6 per cent).35 Brethuaer et al. selected
the studies on primary SG separately and found a mortality rate in this
series of only 0.17 per cent comparable to laparoscopic gastric banding.36
It has been suggested that SG might have an adverse effect on the
function of the lower oesophageal sphincter due to gastric resection at the
angle of His, predisposing the patient to postoperative reflux symptoms.
Himpens et al. showed GORD incidence of 21.8 per cent at one year
follow-up with subjective improvement of the symptoms (3.1 per cent) at
three years.15 Melissas et al. showed that gastric emptying was accelerated
after SG a physiological change that might play a beneficial role in
improving GORD symptoms gradually over time.24 We have to take into
account that one third of the patients might need treatment with proton
pump inhibitors in the first year after the operation.
The German registry data analysed by Stroh show us another impor-
tant issue about SG. In this report there is a rather high leakage rate of 7
per cent and a mortality rate of 1.2 per cent. SG was performed at 17 dif-
ferent hospitals, and the volume of surgeries performed at each ranged
from one to 67 operations. Only three hospitals carried out more than ten
operations per year. In contrast the leakage and mortality rate of the
Spanish registry is much lower: 2 per cent and 0.36 per cent respectively.
This can probably be explained by the fact that the same number of hos-
pitals treated four times as many patients.27 In this respect, it is important
to stress that an SG is probably technically more demanding than it looks.
Sillechia et al. published their learning curve: for the first 40 cases, the
incidence of major complications was 9/40 (22.5 per cent), higher than in
the last 45 cases, which had a complication rate of 5/47 (10.6 per cent).37
In addition the patients have the same high-risk profile as those patients
subjected to other bariatric operations. Adequate training and an experi-
enced team are obligatory and will provide better results with SG in the
future. There is still nothing proven about the necessity to use stapler line
reinforcement or to place sutures to prevent leaks and/or bleeding. The
studies concerning this topic are missing power or randomization.27,38
New Technologies in Bariatric Surgery
209

Long term
In the long term SG will probably have a benefit over RYGB: it does not
involve any digestive anastomosis, no mesenteric defects are created
(eliminating the risk of internal hernia), no foreign material is used as in
the case of gastric banding and the whole digestive tract remains accessi-
ble to endoscopy. It is not associated with dumping syndrome, the risk of
peptic ulcer is low and the absorption of nutrients, vitamins, minerals and
drugs is less altered.11
Concerning vitamin deficiencies it is important to stress that around 15
per cent of the morbidly obese patients already have deficiencies before sur-
gery. Theoretically patients are prone to develop vitamin B12 and iron
deficiency after SG. In one study mean ferritin levels decreased significantly
but stayed well within the normal range, without any patient developing
deficiency after one year.39 In another, development of iron deficiency was
4.9 per cent and insignificant compared to the higher rate after RYGBP.40
Longer term follow-up data are of course essential to detect compli-
cations. The most important topic will be weight regain or insufficient
weight loss.
Mechanisms of action
Weight loss
As mentioned before the weight loss cannot be explained by a purely
restrictive mechanism because of the lack of a restrictive outlet of the
small gastric sleeve. Nevertheless the resected part of the stomach, due to
the massive compliance of the fundus, is more than 90 per cent of the total
stomach capacity;2 see Fig. 2 (a) and (b).
We propose two possible mechanisms that individually or synergisti-
cally act on the process of losing weight by reducing the feeling of hunger
and inducing early satiety:
1.
the consistent acute deprivation of ghrelin;
2.
a rapid emptying of the SG induces a possible RYGBP effect in
the proximal jejunum through an increase of GLP-1 and PYY levels
postprandial. These hormonal alterations decrease hunger and induce
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New Technologies in Bariatric Surgery
211
Figure 2.
(a) Resected part of the stomach. (b) Resected part after injection of 2000 cc
of saline.

early satiety. This mechanism may exert an additional positive effect
on glucose homeastasis.24,41
The hormonal modifications induced by SG differ from those found after
a purely restrictive procedure like laparoscopic adjustable gastric banding.
Ghrelin, a peptide hormone mainly produced in the fundus of the stom-
ach, is involved in the mechanisms regulating hunger. It is secreted by the
endocrine cells of the stomach (X/A-like cells), which reside in the oxyn-
tic glands of the gastric fundus. The gastric fundus contains 10–20 times
more ghrelin per gram of tissue than the duodenum, with diminishing con-
centrations being found in the jejunum and ileum. Ghrelin regulates the
secretion of growth hormone release and is a potent appetite-stimulating
peptide. This last effect is mediated by the activation of ghrelin receptors
in the hypothalamus/pituitary area.42
A decrease of circulating ghrelin levels occurs due to resection of the
gastric fundus where this orexigenic hormone is primarily secreted.43 It
was reported that ghrelin is significantly reduced after SG but not after
LAGB.44 This reduction remains stable at follow-up six months postoper-
atively, which may contribute to the superior weight-loss of SG when
compared with LAGB. A recent prospective randomized double-blinded
study by Karamanakos et al. compared the postoperative hormonal levels
in RYGB to SG: the reduction in the fasting ghrelin levels and increase in
peptide YY are greater in the SG group.16 Weight loss and the loss of feel-
ings of hunger after one and three years are better after SG than LAGB.15
Another possible mechanism of weight loss after SG is accelerated
gastric emptying. Bergmann et al. showed a correlation between echo-
graphic gastric emptying and appetite, where the antral expansion causes
less hunger, an anatomical change achieved by the SG.45 This rapid emp-
tying for food and solids was confirmed on gastric emptying scintigraphy
but discordant with the data of Rosenthal et al. who evaluated the patients
pre- and postoperatively.46,47
Diabetes
The effect of exclusion of the duodenum in RYGBP could be mimicked
by the rapid emptying of food into the proximal intestine. This could
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explain the good early results of SG on type II diabetes.33 The rapid and
profound effect on glucose metabolism, very similar to that seen after gas-
tric bypass, could also be due to an increase of circulating GLP-1 and
PYY. This has been confirmed recently by Peterli et al. who showed a
similar increase in meal-stimulated GLP-1 immediately after SG and
RYGBP in a randomized comparative study.34
Indications
SG as part of a two-step approach in super-obese patient (BMI > 55)
Although in some very experienced hands there is no difference in co-
morbidity and mortality between super-obese patient and the morbidly
obese patient, it is overall safer to perform first a sleeve gastrectomy.48
When after one year significant weight loss is established, a second step
procedure (RYGBP or BPD-DS) is performed in case of insufficient
weight loss and/or insufficient controlled co-morbidities.18
SG as a primary bariatric operation
There is hesitancy in confirming this in the literature. The main reason is
probably that cataloguing SG as a bariatric procedure in itself is prema-
ture due to the lack of sufficient long term follow-up data (< 4 years of
follow-up). In consequence SG can be proposed to a patient but fully
informed consent and understanding about the probability of a second
operation in case of insufficient weight loss or eventual weight regain is
mandatory. This should in fact be required for every bariatric procedure.
On the other hand the short term weight loss data, which are similar to
RYGBP, and the excellent metabolic control after SG are confirmed and
likely to be sufficient confirmation.
SG is the best option in certain specific clinical situations
When the patient has had extensive abdominal surgery in the lower
abdomen SG is the safest option.
In patients with Crohn’s disease and colitis ulcerosa, compromising
the small intestine is avoided when performing an SG.
New Technologies in Bariatric Surgery
213

In cases of persistent Helicobacter pylori (HP) infection after multi-
ple eradication schemes or in populations at high risk for stomach cancer,
SG is the only option. There are observations that pylorus-preserving
surgery might even lead to HP eradication.49
SG is a good alternative in the young patient because of the preserved
duodenal calcium absorption necessary to complete the bone formation
that continues until the age of 25. Dumping syndromes can cause many
problems in the hectic life style of adolescents. The elderly benefit more
from a short operation with a low mortality that controls co-morbidities.
Long term results are less important and quality of life is of primary
importance. Laparoscopic banding is known to have bad results in these
two subpopulations of patients.
Given the shorter operating time it can be beneficial to perform an SG
in patients with ASA IV. There is always the possibility of performing a
second stage operation later when the ASA score has improved.
It is clear that a BPD–DS operation is potentially hazardous in patients
non-compliant towards eating habits and/or follow-up. On the other hand
it is probably true that a subpopulation of morbidly obese patients are not
sufficiently treated with a gastric bypass, for example the super-obese,
sweet eaters and grazers. In these patients it is advisable first to perform an
SG and then to check that the postoperative diet contains sufficient proteins
and that there is no snacking. Given a good follow-up, a BPD–DS can
safely be performed in this patient. SG is an ideal tool for patient tailoring.
More and more patients are being introduced to bariatric surgery
before or after transplant procedures, and SG has several advantages in
this setting. In the case of liver transplantation specifically, stable
immunosuppressive medication trough levels and access to the biliary
tract are attractive advantages. In dialysis patients, SG is more likely to
preserve a good peritoneal dialysis and adequate immunosuppressant state
after kidney transplantation.
New Minimally Invasive Techniques in Bariatric Surgery
Natural orifice transluminal endoscopic surgery
Natural Orifice Transluminal Endoscopic Surgery (NOTES) is the term
that covers all conventional surgical procedures that are performed after
214
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gaining access to the peritoneum or retroperitoneum via natural body open-
ings such as the mouth, anus, vagina and bladder. The motivating factor for
NOTES is that elimination of abdominal scars will further reduce the inva-
siveness of surgery resulting in less pain, shortened convalescence,
improved cosmesis and absence of abdominal wound infections and
hernias. Although this hypothesis is largely unproven and many significant
hurdles exist for application of natural orifice surgery, since the first report
on NOTES by Kalloo et al. in 2004, there has been great enthusiasm with
regard to different diagnostic and therapeutic interventions and much
financial and research effort has been undertaken. The NOTES concept has
been triggering many technological innovations broadly applicable to min-
imally invasive diagnostic and therapeutic strategies.
In recent years multiple feasibility and safety studies in animals
(mainly pigs) have been reported. To date, the first NOTEStm case reports
and small series reported on humans have mainly used cholecystectomy
as an educational and research model. This study acts as a bridge between
the classic field of laparoscopic surgery and conventional endoscopic pro-
cedures to facilitate the progress of NOTEStm. Most issues addressed in
the 2006 White Paper by Rattner et al. have been dealt with, such as
access to the peritoneal cavity, intestinal closure, prevention of infection
and management of complications and physiologic events, such as
intraperitoneal pressure measurements.
In animal models multiple groups are performing NOTES or hybrid
NOTES, with the use of additional trocars. An SG in a porcine model
using vaginal route visualization and additional 12 mm portal for the sta-
pler and 2 2mm portals for traction purposes has been reported.50 Others
used the rectum as the port of entry to the peritoneal cavity, and the stom-
ach was manipulated endoluminally using a gastroscope, the gastric
remnant being removed through the rectal incision. Successful operations
on five pigs were reported.51
One group stated that as a gastrotomy is part of the procedure anyway,
RYGB might be a procedure that is suited for NOTES through the oral
route. They performed a combined transvaginal and transgastric gastric
bypass (TVTG-GBP) in a human cadaver.52
Recently it has become more and more apparent that transvaginal
NOTES represents the safest and most applicable natural orifice route. It
New Technologies in Bariatric Surgery
215

is relatively independent of advanced technological development, with a
potential benefit of easy decontamination, controllable access and easy
closure under direct vision. The safety of the transvaginal route also has
been well documented for numerous gynaecologic procedures. In addi-
tion, the transvaginal route seems logical for most upper abdominal
procedures. Male patients clearly cannot be operated upon in this way.
The largest series consisting of two successful cases were submucosal
tumours which were resected in a full NOTES procedure.53
It is too early to highlight any advantage of NOTES in bariatric sur-
gery. It will be imperative to gain more than only a cosmetic benefit when
implementing difficult and potentially more dangerous procedures in a
subject as difficult as a morbidly obese patient. On the other hand it is an
outstanding platform for the development of new materials and new meta-
bolic and bariatric procedures.
Single incision laparoscopic surgery
Single incision laparoscopic surgery (SILS), also known as laparoendo-
scopic single-site surgery or single-port access surgery, is an area of active
investigation for abdominal surgery with more immediate applicability in
the clinics on first sight. Although the advantages that have been proposed
include cosmetics (scarless abdominal surgery performed through an
umbilical incision), less incisional pain and the ability to convert to stan-
dard multiport laparoscopic surgery if needed, these are less convincing in
a bariatric surgery setting.
Single-access laparoscopy involves the introduction of special
multichannel access devices that allow laparoscopic surgery to be per-
formed through one incision. Ideally this is done with special
instruments and endoscopes that are currently being developed. Several
access devices are available to insert two or three instruments and a
scope into the abdomen through an umbilical incision in an airtight
fashion. The potential advantages of this approach are related to limit-
ing the port incisions to one site, in addition to the advantages of
traditional minimally invasive surgery. Positioning the single access
within the umbilicus results in better cosmetics and avoids muscle
penetration, which minimizes incision pain.
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Single incision cholecystectomy was described by Piskun et al. as
early as 1999, with the insertion of two trocars through the umbilical
incision and additional stay sutures to stabilize the gallbladder.54 Today
almost all common laparoscopic procedures are performed with SILS
technology.55
The first bariatric operation through a single incision was a gastric
banding. In this case the whole operation was performed through a single
supra-umbilical incision, necessary to place the port and to introduce the
band.51,56 The SG is of course a better procedure to be performed scarless
using the SILS technology, because of the absence of any foreign body
material that has to be introduced. The groups of Nguyen et al. and Reavis
et al. describe the first successful procedure through an 2.5 cm supra-
umbilical incision and one year later, without any visible scar, through an
incision in the umbilicus, the latest natural orifice to be used.57,58 The
largest series describes a total of seven successful single-incision tran-
sumbilical laparoscopic SGs. Two patients required lysis for adhesions,
one patient underwent an umbilical hernia repair during the procedure and
one patient required the insertion of an additional trocar. The mean oper-
ating time was 143 minutes. There were no mortalities or postoperative
complications noted during the mean follow-up period of 1.5 months.59
One possible complication related to the technique is an umbilical hernia;
the follow-up data in the published studies are too short to exclude this.
Many new instruments, trocars and flexible laparoscopes have been
developed in recent years and will now become commercially available.
In consequence the SILS technology will be available for every bariatric
surgeon. Nevertheless it is very important to realize that there will be an
important learning curve, which may result in possibly devastating com-
plications in a morbidly obese patient. The necessary technology to
perform full NOTES procedures and the validation of standard techniques
are not yet available, so it is only performed in research settings and
mainly in animal models.
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16. Karamanakos, S.N., Vagenas, K., Kalfarentzos, F. et al. (2008). Weight loss,
appetite suppression, and changes in fasting and postprandial ghrelin and
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prospective, double blind study. Ann Surg 247(3): 401–407.
17. Nocca, D., Krawczykowsky, D., Bomans, B. et al. (2008). A prospective
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a risk reduction strategy. Obes Surg 18(12): 1575–1580.
19. Fuks, D., Verhaeghe, P., Brehant, O. et al. (2009). Results of laparoscopic
sleeve gastrectomy: a prospective study in 135 patients with morbid obesity.
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20. Uglioni, B., Wolnerhanssen, B., Peters, T. et al. (2009). Midterm results of
primary vs. secondary laparoscopic sleeve gastrectomy (LSG) as an isolated
operation. Obes Surg 19(4): 401–406.
21. Rubin, M., Yehoshua, R.T., Stein, M. et al. (2008). Laparoscopic sleeve gas-
trectomy with minimal morbidity early results in 120 morbidly obese
patients. Obes Surg 18: 1567–1570.
22. Vidal, J., Ibarzabal, A., Romero, F. et al. (2008). Type II diabetes mellitus
and the metabolic syndrome following sleeve gastrectomy in severely obese
subjects. Obes Surg 18(9): 1077–1082.
23. Lee, C.M., Cirangle, P.T., Jossart, G.H. (2007). Vertical gastrectomy for mor-
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24. Melissas, J., Koukouraki, S., Askoxylakis, J. et al. (2007). Sleeve gastrec-
tomy: a restrictive procedure? Obes Surg 17(1): 57–62.
25. Menenakos, E.M., Stamou, K., Albanopoulos, K. et al. (2010). Laparoscopic
sleeve gastrectomy performed with intent to treat morbid obesity: a prospec-
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26. Jacobs, M., Bisland, W., Gomez, E. et al. (2010). Laparoscopic sleeve gas-
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781–785.
27. Sanchez-Santos, R., Masdevall, C., Baltasar, A. et al. (2009). Short- and mid-
term outcomes of sleeve gastrectomy for morbid obesity: the experience of
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28. Stroh, C., Birk, D., Flade-Kuthe, R. et al. (2009). Results of sleeve gastrec-
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29. Colquitt, J.L., Picot, J., Loveman, E. (2009). Surgery for obesity. Cochrane
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30. Cottam, D., Qureshi, F.G., Mattar, S.G. et al. (2006). Laparoscopic sleeve
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31. Moon Han, S., Kim, W.W., Oh, J.H. (2005). Results of laparoscopic sleeve
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32. Shah, P.S., Todkar, J.S., Shah, S.S. (2010). Effectiveness of laparoscopic
sleeve gastrectomy on glycemic control in obese Indians with type II dia-
betes mellitus. Surg Obes Relat Dis 6(2): 138–141.
33. Rosenthal, R., Li, X., Samuel, S. et al. (2009). Effect of sleeve gastrectomy
on patients with diabetes mellitus. Surg Obes Relat Dis 5(4): 429–434.
34. Peterli, R., Wolnerhanssen, B., Peters, T. et al. (2009). Improvement in glu-
cose metabolism after bariatric surgery: comparison of laparoscopic
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tive randomized trial. Ann Surg 250(2): 234–241.
35. Akkary, E., Duffy, A., Bell, R. (2008). Deciphering the sleeve: technique, indica-
tions, efficacy, and safety of sleeve gastrectomy. Obes Surg 18(10): 1323–1329.
36. Brethauer, S.A., Hammel, J.P., Schauer, P.R. (2009). Systematic review of
sleeve gastrectomy as staging and primary bariatric procedure. Surg Obes
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37. Silecchia, G., Rizzello, M., Casella, G. et al. (2009). Two-stage laparoscopic bil-
iopancreatic diversion with duodenal switch as treatment of high-risk
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38. Assalia, A., Ueda, K., Matteotti, R. et al. (2007). Staple-line reinforcement
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41. Wang, Y., Liu, J. (2009). Plasma ghrelin modulation in gastric band opera-
tion and sleeve gastrectomy. Obes Surg 19(3): 357–362.
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releasing acylated peptide from stomach. Nature 402(6762): 656–660.
43. Cummings, D.E., Weigle, D.S., Frayo, R.S. et al. (2002). Plasma ghrelin lev-
els after diet-induced weight loss or gastric bypass surgery. N Engl J Med
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47. Braghetto, I., Davanzo, C., Korn, O. et al. (2009). Scintigraphic evaluation
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49. Keren, D., Matter, I., Rainis, T. et al. (2009). Sleeve gastrectomy leads to
Helicobacter pylori eradication. Obes Surg 19(6): 751–756.
50. Marchesini, J.C., Cardoso, A.R., Nora, M. et al. (2008). Laparoscopic sleeve
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51. Mintz, Y., Horgan, S., Savu, M.K. et al. (2008). Hybrid natural orifice
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52. Madan, A.K., Tichansky, D.S., Khan, K.A. (2008). Natural orifice translu-
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Chapter 9
Imaging of Complications After
Bariatric Surgery
Jose C. Varghese and Shuvro H. Roy-Choudhury
Introduction
Weight reduction (bariatric) surgery can be of the malabsorptive, restric-
tive or mixed types, depending on the anatomical and physiological
alterations surgically brought about to effect weight loss. The earlier
purely malabsorptive surgeries have latterly given way to the more restric-
tive and mixed types because of improved patient tolerance and safety.1–3
Currently, the most popular type of bariatric surgery in Europe is the
laparoscopic adjustable gastric banding (LAGB), and that in the United
States is the Roux-en-Y gastric bypass (RYGB).4
Complications after bariatric surgery can be broadly categorized as
enteric or nonenteric in origin. The enteric complications — such as
obstruction, perforation and herniation — often require reoperation for
treatment. In contrast, the nonenteric complications — such as pul-
monary embolism, myocardial infarction and infection — are treated
medically. The remainder of the chapter will deal with the diagnosis and
management of enteric complications that are often specific to bariatric
surgery.
Imaging plays a vital role in the diagnosis and management of com-
plications after bariatric surgery.5–8 The upper gastrointestinal (UGI)
series and computed tomography (CT) are by far the two most commonly
used modalities in this regard. The UGI provides endoluminal and
223

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J. C. Varghese and S. H. Roy-Choudhury
functional information related to the gastrointestinal tract itself, whilst CT
provides a more comprehensive tomographic visualization of the extra-
luminal structures. In addition, ultrasonography, nuclear scintigraphy and
interventional radiology all have their limited but specific uses.
Laparoscopic Adjustable Gastric Banding
Laparoscopic adjustable gastric banding (LAGB) is the most commonly
performed weight reduction surgery in Europe, with over 300,000 proce-
dures having been performed worldwide to date.9 It is a purely restrictive
type of surgery that is designed to reduce receptive gastric volume, lead-
ing to early satiety and weight loss. The procedure involves the wrapping
of a silicone band — with an attached inner lining balloon — around the
upper stomach, to segment a small proximal portion of the stomach (the
‘pouch’) from the remainder of the distal stomach. The band is held in
position by its circular wrapping effect, its positioning above the lesser
omentum (using a pars flaccida technique), and the burying of the anterior
portion of the band in a seromuscular tunnel (Fig. 1a) formed by gastro-
gastric over sewing of the anterior gastric wall. The luminal constriction
produced by the band is called the ‘stoma’, and its size is adjusted by
inflation or deflation of the inner lining balloon using fluid injected
through a subcutaneous port (Fig. 1b).
This combined restriction brought about by a small gastric pouch
(< 15 ml in volume) and narrow stoma (2–4 mm in diameter) results in the
feeling of early satiety after eating of small quantities of food, leading to
weight loss. With appropriate patient selection, this technique can lead to
a steady and sustained excess weight loss of around 62 per cent at three
years.10 However, complications can be frequent with a yearly major com-
plication rate of 3–4 per cent,11 and reoperation rate of 0.8–21 per cent.11,12
Therefore, LAGB patients require close scrutiny in the days and months
following surgery, and radiology plays an important part in this process.
The main imaging modality used to investigate patients after LAGB
is the UGI series. The three main indications for performing UGI are to:
1.
document baseline anatomy;
2.
diagnose post-surgical complications;
3.
guide port access/band adjustment.

Imaging of Complications After Bariatric Surgery
225
(a)
(b)
Figure 1. Laparoscopic adjustable gastric band. (a) Schematic diagram of a laparoscopic
adjustable gastric band placed across the proximal stomach — above the insertion of the
lesser omentum (suprabursal placement) — to create a ‘neostomach’ or pouch (arrow).
This suprabursal placement reduces the risk of slippage. Slippage is further reduced by
fixation of anterior band using seromuscular gastro-gastric sutures (inset). (Images by
courtesy of BioEnterics Corp, MA, USA, and reprinted with permission from Dr. Shuvro
H. Roy-Choudhury and Elsevier.8 (b) Photograph of a laparoscopic adjustable band
showing a port (arrow) connected to the band through a connecting tube (arrowhead). This
port can be accessed externally like other similar devices. Filling the port fills an inflatable
circumferential reservoir (not shown) around the inside of the band, which can tighten
the stoma.

An UGI is usually performed at 6–12 weeks after the initial surgery to
evaluate the baseline anatomy, diagnose early complications and assist in
band inflation. Occasionally an UGI series and/or CT is performed in the
immediate post-operative period to diagnose postoperative leak or cause
of acute dysphagia. It is also performed as required in symptomatic
patients to diagnose intercurrent complications and for band adjustment
when there is a plateau in weight loss.
Early post-operative evaluation
An UGI is usually performed at around 6–12 weeks after initial surgery to
evaluate baseline anatomy, diagnose early complications and guide stomal
adjustment.
Imaging technique
A control film is taken to evaluate the position and orientation of the band,
tubing and port (Fig. 2a). Following this, a semi erect barium swallow in
the frontal and lateral projections is performed to evaluate oesophageal
transit and any evidence of obstruction (Fig. 2b). If the initial study is nor-
mal, the procedure can be continued with the use of thick barium for
stomal adjustment as described below.
Baseline anatomy
Some of the baseline imaging characteristics of a normal LAGB is as
follows:
•
the silicone band should lie approximately 1–2 cm below the
gastro-oesophageal junction;
•
the band should lie 30–45° inclined to the horizontal plane in the AP
projection;
•
the pouch should measure less than 15 ml in volume;
•
the stoma should be large enough to allow passage of contrast medium
without obstruction and, yet, tight enough to cause restriction (2–4 mm).
A normal early UGI after LAGB is shown in Fig. 2.
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Imaging of Complications After Bariatric Surgery
227
(a)
(b)
Figure 2.
Normal postoperative appearance at barium swallow performed eight weeks
following surgery. (a) Control film showing band faintly seen (between two arrows), but
normally angled (30–45°) to the horizontal. The port is seen connected to the band through
a connecting tube without any kink. (b) An initial contrast swallow in the anteroposterior
(AP) projection shows unobstructed passage of contrast through the band with a wide
stoma. Stomal size may be calculated by calibrating with the known diameter of the band.
A lateral/oblique swallow examination should also be performed (not shown) to ensure the
band is around the stomach. Reprinted with permission of Dr. Shuvro H. Roy-Choudhury
and Elsevier.8

Early postoperative complications
Possible early post-operative complications would include obstruction,
perforation and haemorrhage. These complications are often technical in
origin and their incidence varies according to the surgical technique
used and operator experience. Complications of obstruction, band
slippage and gastric herniation are fairly obvious at UGI and are further
discussed below. Perforation may be obvious on the UGI series (Fig. 3a),
but continued clinical concern for perforation or haemorrhage in the
face of a normal UGI mandates a CT. The latter may show extraluminal
gas (Fig. 3b) and intra-abdominal fluid collections (Fig. 3c) indicative
of perforation, or intra-abdominal high-density fluid indicative of
haemorrhage.
Port access and stomal adjustment
The LAGB balloon is not fully inflated at the time of surgery to allow time
for healing and resolution of oedema. Despite this, some weight reduction
ensues in the immediate post-operative period due to the baseline con-
strictive effect of the device. However, from around 6–12 weeks after
surgery and periodically thereafter — based on rate of patient weight
loss — graduated inflation of the balloon is required to promote sustained
weight loss.
The process of balloon inflation with stomal tightening can be per-
formed with5,8,13 or without14 fluoroscopic guidance. If fluoroscopic
guidance is used, a modified UGI technique is recommended that
includes the use of thick barium to fully distend the pouch, visualization
of the stoma in anterior and lateral projections, and an imaging rate of
at least two frames per second to accurately measure stomal size.8,15 A
left anterior oblique projection can be useful when the band is obscured
after the initial swallows. The port is accessed using a sterile technique
and a non-coring needle, similar to the techniques used with traditional
chemotherapy ports. A C-arm device and appropriate angulation may be
useful to view a tilted port end-on (Fig. 4a) to facilitate puncture.
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Imaging of Complications After Bariatric Surgery
229
(a)
(b)
(c)
Figure 3.
Early perforation after laparoscopic gastric banding. (a) Water soluble con-
trast swallow performed 96 hours after surgery shows a leak from the distal oesophagus
(arrow), just above the gastro-oesophageal junction. (b) Axial CT through upper
abdomen after the contrast swallow shows free air (long arrows) adjacent to the band
(small arrows) indicating perforation. (c) Axial CT just below (b) shows inflammation
extending along the connecting tube (large arrow) with loculated fluid collection (small
arrows).

Occasionally ultrasound may be useful to localize and puncture the port
if fluoroscopy is impossible (due to weight limit of tables) or difficult.
Several generations of bands have been used over the last ten years and
an accurate knowledge of their normal appearances and reservoir capacity
is critical to optimally inflate the band. Reservoir capacity varies from
4–14 ml, with the later generation of larger bands having a greater capacity.
Based on the band used, 1–8 ml of normal saline (or water soluble contrast
medium, see below) is injected to adjust stomal size to around 2–4 mm in
diameter, that is sufficient to cause mild hold-up to barium without caus-
ing total obstruction.5,8,13 This assessment requires experience, but a rule of
thumb is that the barium should clear from the pouch within two or three
peristalsis without persistent gastro-oesophageal reflux (Figs 4b, 4c).
The advantages of using fluoroscopic guidance are the following:
1.
increased ease and success of port localization/puncture;
2.
increased accuracy of stomal size adjustments (patient sensation of
hold-up correlates poorly with optimal stomal size, particularly with
the older bands where as little as 0.5 ml of injectate may make a
difference between optimal tightening and over-tightening);
3.
the opportunity to diagnose occult complications related to the
stomach or the prosthesis.
One group has reported the use of dynamic radioisotope scintigraphy as a
superior method for band adjustment.16
Diagnosis of postoperative complications
Complications after LAGB can be related to:
1.
the stomach (e.g. gastro-oesophageal reflux, pouch dilatation,
obstruction, herniation);
2.
the prosthesis used (silicone band, balloon, connecting tubing,
subcutaneous port);
3.
surgery in general (e.g. pulmonary embolism, wound infection).
These complications can occur in the early (< 30 days), or the late
post-operative period (> 30 days).
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Imaging of Complications After Bariatric Surgery
231
(a)
(b)
(c)
Figure 4.
A typical radiological band adjustment sequence following normal assess-
ment. (a) The port is localized; sometimes oblique screening may facilitate port puncture.
(b and c) Dilute contrast solution is injected through the port in a graduated manner with
intermittent check barium swallows. Optimal amount depends on the type of band and
requires some experience. Radiological adjustment is often subjective with clearance after
two or three peristaltic waves being about right. Adjustment should also take into account
the specific patient’s needs and the weight loss curve. With smaller bands, fine adjustment
may be necessary with 0.5 ml making the critical difference.