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Single-port sleeve gastrectomy for super-obese patients
Surgery for Obesity and Related Diseases 12 (2016) 522–527
Original article
Single-port sleeve gastrectomy for super-obese patients Guillaume Pourcher, M.D.a,b,c,d, Stefano Ferretti, M.D.a,b, William Akakpo, M.D.a, Panagiotis Lainas, M.D., Ph.D.a,b,c,d, Hadrien Tranchart, M.D.a,b,c,d, Ibrahim Dagher, M.D., Ph.D.a,b,c,d a
Department of Minimally Invasive digestive Surgery, Hôpital Antoine Béclère, AP-HP, Clamart, France b Paris-Sud University, Kremlin-Bicêtre, France c Inserm, Unité 1193, Villejuif, France d DHU Hepatinov, Villejuif, France Received March 29, 2015; accepted December 1, 2015
Abstract
Background: Laparoscopic sleeve gastrectomy, which has become a primary bariatric procedure in super-obese patients (SOPs), is associated with considerable weight loss. Traditionally, laparoscopic sleeve gastrectomy requires 4–7 skin incisions. Single-port laparoscopic surgery is now feasible for bariatric surgery. Objectives: To evaluate the feasibility and safety of single-port sleeve gastrectomy (SPSG) for SOPs. Setting: Department of Abdominal and Minimally Invasive Surgery, Antoine Beclere Hospital, Assistance Publique-Hôpitaux de Paris, Paris-Sud University, France. Methods: Evaluation of the outcomes on patients who underwent surgery consecutively from June 2010 to June 2013 with follow-up of 41 year. Results: In total, 62 patients (46 women, 16 men) underwent SPSG. The median age was 41 years (range 19–67), median preoperative body mass index was 52.2 kg/m2 (range 50–87), median operative time was 89 minutes (range 42–212). Twelve patients required additional trocars, and 4.8 % developed complications. The median postoperative stay was 4 days (range 3–9 days) and median follow-up period was 21 months (range 12–48 months) with no loss of follow-up. The median percentage of excess weight loss was 69.7% (range 52%–100%) and percentage of weight loss was 36% (28%–56%) for the same period. Conclusion: SPSG for SOPs was found to be technically feasible, reproducible, and safe in this series. (Surg Obes Relat Dis 2016;12:522–527.) r 2016 Published by Elsevier Inc. on behalf of American Society for Metabolic and Bariatric Surgery.
Keywords:
Super-obese; Bariatric; Single port; Sleeve
Bariatric surgery is a widely accepted treatment for morbid obesity with very encouraging outcomes [1,2]. It induces long-term weight loss and leads to improvement or remission of associated diseases, such as type 2 diabetes mellitus and hypertension [1,3]. Laparoscopic sleeve gastrectomy (LSG) has become an established primary bariatric surgical technique, gaining popularity among surgeons during the last 5 years. LSG has an acceptable morbidity
and long-term weight loss results compared with the laparoscopic Roux-en-Y gastric bypass and adjustable gastric banding [4–6]. It is a relatively simple operation, thus being especially attractive for high-risk patients [7–9]. Recent studies have shown that male gender, advanced age, presence of multiple co-morbidities, and increased body mass index (BMI) are associated with higher morbidity and mortality rates in
http://dx.doi.org/10.1016/j.soard.2015.12.001 1550-7289/r 2016 Published by Elsevier Inc. on behalf of American Society for Metabolic and Bariatric Surgery.
SPSG for Super-obese Patients / Surgery for Obesity and Related Diseases 12 (2016) 522–527
bariatric surgery patients [10–12]. LSG has been used for super-obese patients (SOPs), defined by a BMI 450 kg/m2, providing satisfactory weight loss and the desired results [11,13]. Single-port laparoscopy has been shown to be safe and minimally invasive for performing a variety of abdominal procedures. The first single-port laparoscopic sleeve gastrectomy (SPSG) was described in 2008 by Saber et al. [14]. SPSG could also be of particular interest for high-risk patients, such as SOPs. However, only 2 studies have evaluated the operative and postoperative effects of SPSG on SOPs, with each study analyzing o10 patients [14,15]. The aim of this study was to report our experience of SPSG for SOPs in our series of consecutive patients. Patients and methods All SOPs (BMI 450 kg/m2) who underwent SPSG in our department from June 2010 to June 2013 were included in our study. The indications for bariatric surgery were in accordance with the French recommendations [16]. All patients underwent meticulous evaluation before surgery by a multidisciplinary team consisting of an endocrinologist, a gastroenterologist, a psychiatrist, a nutritionist, an anesthesiologist, and a surgeon. Appropriate preoperative investigations were performed, as indicated (esophagogastroduodenoscopy, upper gastrointestinal series, abdominal ultrasonography, polysomnography, and endocrinologic and nutritional evaluations). All patients were informed about the innovative nature of this technique and gave written informed consent before surgery, and the study was approved by the hospital institutional review board. Comorbidities were defined according to the international standard criteria (Table 1)—gastroesophageal reflux disease: need for proton pump inhibitor agents and/or esophagitis diagnosed on endoscopy and/or abnormal manometry; arthralgia: clinical and radiological findings. Remission and improvement of co-morbidities were defined by the endocrinologist/physician responsible for the followup. Remission was considered to have occurred when the value was normalized and improvement when the treatment was decreased.
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Operative technique Since the introduction of SPSG in our department, we have employed the same technique, as previously described [17]. Briefly, access is obtained through a 2- to 4-cm skin incision in the left upper quadrant, using an open technique for the introduction of the single port. The single-port device (Quad-Port, Olympus Medical, Nagano, Japan) consists of 2 ports of 5 mm, 1 port of 15 mm, and 2 ports of 12 mm. A 10-mm flexible tip laparoscope (LTF-VH or EndoEYE LS, Olympus Medical) or a 10-mm rigid co-axial 301 laparoscope is used. A double-curved nontraumatic grasper is used in the left hand for exposure, and a 5-mm thermofusion device (LigaSure, Covidien, France; or Thunderbeat, Olympus Medical) or the stapler in the right hand. The omentum is initially separated from the stomach, and the corpus is freed up to the left pillar of the diaphragm. This gastrolysis is obtained with the posterior dissection, section, and coagulation of the right gastro-omental vessels around the stomach and the short gastric vessels by using thermofusion grasper. When the angle of His is freed, the sleeve of the stomach is created over a 36-F bougie, after introduction of the orogastric tube along the lesser curvature, and transection of the stomach is done with the use of 60-mm endoscopic staplers, starting 6 to 7 cm proximal to the pylorus and heading toward the left side of the gastroesophageal junction. We use the same stapling over the stomach (Endo-GIA Tri-Staple by Covidien, Elancourt, France; or Echelon Flex powered by Ethicon, Issy-lesMoulineaux, France). For patients with a history of Lapband, we use a reinforced stapler (Perstrip by Baxter or Syngard by Gore). At the end of transection, the specimen is easily removed through the single port. The parietal wall incision is closed for all patients with 2 layers by using Vicryl 1. Then the skin is closed as usual with Vicryl fast 3/0. Drainage is not performed routinely but is only done in cases of particularly difficult gastric dissection. A urinary catheter or a nasogastric tube is never used. Postoperative management and follow-up In our study, abdominal computed tomography (CT) was routinely performed 2 days after surgery to rule out gastric
Table 1 International criteria defining the co-morbidities Co-morbidities
Definitions
Hypertension Type 2 diabetes
Systolic blood pressure 140 mm Hg or more and/or diastolic blood pressure Z90 mm Hg or antihypertensive drug therapy. On plasma glucose criteria, either the fasting plasma glucose (FPG), pathologic value is FPG 4126 mg/dL (7.0 mmol/L) or the 2-hour plasma glucose value 4200 mg/dL (11.1 mmol/L) after a 75-g oral glucose tolerance test. Recently, an International Expert Committee added the A1C (threshold Z6.5%) as a third option to diagnose type 2 diabetes Fasting high-density lipoprotein o40 mg/dL for men, o50 mg/dL for women, and/or triglycerides 4150 mg/dL and/or lowdensity lipoprotein 4100 mg/dL or the use of statins. Repeated upper airway occlusions during sleep with or without sleepiness and high apnea/hypopnea index and the need for continuous positive airway pressure during sleep.
Dyslipidemia Obstructive sleep apnea syndrome
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leak and hemorrhage/hematoma. Patients were evaluated by a dietary specialist at 15 days and 3 months after surgery. The surgeon followed up on the patients at 1, 3, and 6 months postoperatively. The dynamic result was assessed by a follow-up study of esophagogastroduodenal transit at 3 months and CT at 1 year. The efficacy of care was assessed by calculating the bariatric analysis and reporting outcome system score 1 year after surgery [18], and it was evaluated as a failure, fair, good, very good, or excellent [18]. Weight loss and remission of co-morbidities were assessed. Discontinuation of all medication for the treatment of a comorbidity was considered an indication of remission of the respective co-morbidity. Ninety percent of patients with sleep apnea discontinued continuous positive airway pressure use.
Co-morbidities were as follows : T2D in 8 patients (12.9%), hypertension in 30 patients (48.3%), obstructive sleep apnea syndrome in 45 patients (72.5%), hyperlipidemia in 18 patients (29%), degenerative osteoarthritis in 35 patients (56.4%), back pain in 37 patients (59.6%), thromboembolic disease in 6 patients (9.6%), coronary artery disease in 6 patients (9.6%), HIV infection in 3 patients (4.8%), and gastroesophageal reflux disease in 15 patients (24.1%). Twelve patients (19.3%) had previously undergone gastric banding. The gastric band was removed 3 months before SPSG in all patients. Five patients (8%) had previously undergone open surgery (3 cholecystectomies, 1 aortic surgery, and 1 emergency splenectomy).
Intraoperative and postoperative results Statistical analysis Data were prospectively gathered in an electronic database. Variables evaluated were duration of surgery, estimated blood loss, transfusion rate, number of stapler refills used, specific and general morbidity, perioperative mortality, postoperative pain medication requirement, and length of hospital stay. The statistical program Prism version 5.0 (GraphPad Software, La Jolla, CA) was used. Quantitative variables were expressed as mean (range) values, and qualitative variables were expressed as percentages. Results Sixty-two patients were included in our study (Table 2). Median age was 41 years (range 19–67 years) and 46 patients (74.1%) were women. Median weight was 140 kg (range 121–222 kg), with a median BMI of 52.2 kg/m2 (range 50–87 kg/m2). Table 2 Demographic characteristics of patients undergoing single-port sleeve gastrectomy in super-obese patients Patients
n ¼ 62
Age (yr): median (range) Female / male, n Weight (kg): median (range) Smoker, n (%) Body mass index, kg/m2 median (range) Co-morbidities Type 2 diabetes, n (%) Hypertension, n (%) Sleep apnea, n (%) Hyperlipidemia, n (%) Degenerative osteoarthritis, n (%) Back pain, n (%) Thromboembolic disease, n (%) Coronary artery disease, n (%) HIV infection, n (%) Gastroesphageal reflux disease, n (%) Previous gastric band, n (%) Open surgery, n (%)
41 (19–67) 46 / 16 140 (121–222) 7 (11.2) 52.2 (50–87) 8 30 45 18 35 37 6 6 3 15 12 5
(12.9) (48.3) (72.5) (29) (52.3) (59.6) (9.6) (9.6) (4.8) (24.1) (19.3) (8)
Detailed results are provided in Table 3. Median duration of surgery was 89 minutes (range 42–212 minutes). Intraoperative blood loss was minimal (range 0–20 mL), and postoperative bleeding required blood transfusion in 1 patient. All 62 SPSGs were performed without the need for conversion to open surgery. Twelve patients (19.3%) required additional trocars, 8 of them during the first 20 SPSGs. The additional 5-mm trocar was placed in the epigastrium to retract the left liver lobe in 8 patients. In 4 patients, additional trocars were used (∅5–12 mm) in the left hypochondrium for the introduction of the stapler because of conflict of the latter with the other instruments in the single port. Median number of stapler refills used was 5 (range 4–7 refills). The surgical specimen was removed intact through the single port in all cases without having to extend the incision. Table 3 Intraoperative and postoperative results following single-port sleeve gastrectomy in super-obese patients (n ¼ 62) Operating time (min): median (range) Blood loss (mL): median (range) Transfusion, n (%) Number of staplers cartridge/patient: median (range) Additional trocar
Conversion to open surgery, n (%) New surgery for complication Nasogastric or urinary tube, n (%) Analgesia, mg of morphine/kg: median (range) Realimentation (days): median (range) Complications, n (%)
Hospital stay (days): median (range) Death, n (%)
89 (42–212) o10 (0–20) 1 (1.6) 5 (4–7) For the 20 first patients (%) Total, n (%)
8 (40) 12 (19.3)
0 (0) 2 (3.2) 0 (0) 0.38 (0–1.4) 2 (2–3) Hemorrhage 2 (3.2) Leaks 0 (0) Other: (pneumopathy, 2 (3.2) incisional hernia) 4 (3–9) 0 (0)
SPSG for Super-obese Patients / Surgery for Obesity and Related Diseases 12 (2016) 522–527
Two patients (3.2%) had postoperative complications and required surgical treatment on day 2, based on a control CT scan, and 1 of those patients had blood transfusion of 2 units of blood. In both cases, the patients experienced active bleeding, one from the left liver lobe and the other from the gastric staple line. One patient experienced pneumonia, which was successfully treated with antibiotics. No death occurred in the postoperative period. Median postoperative analgesia requirements were .38 mg/kg intravenous morphine sulfate equivalents (range 0–1.4 mg/kg). Median length of hospital stay was 4 days (range 3–9 days). Follow-up Median follow-up period was 21 months (range 12–48 months). The outcomes are summarized in Table 4. The majority of preoperative co-morbidities were found to have resolved during follow-up, including T2D in 60% of patients, hypertension in 65% of patients, obstructive sleep apnea syndrome in 90% of patients, hyperlipidemia in 50% of patients, hip and knee pain in 45% of patients, and back pain in 27% of patients. At least 1 co-morbidity disappeared for each patient. Mortality was nil during follow-up. One patient had an incisional hernia, which was treated 12 months later with surgical repair. Median reduction in excess weight was 69.7%, with all 62 patients losing 450% (range 52%–100%) of their excess weight. The median bariatric analysis and reporting outcome system score 1 year after surgery was 7/9. Discussion LSG provides various advantages, such as shorter duration of surgery, absence of gastrointestinal anastomosis and postoperative internal hernias, and lower incidence of vitamin deficiencies or malabsorption [5,19]. LSG is increasing in popularity, and in the medium-term followup, it is an effective weight loss procedure with an Table 4 Follow-up results after single-port sleeve gastrectomy in super-obese patients (n ¼ 62) Median follow-up, month (range) Preoperative BMI, kg/m2, median (range) Postoperative BMI, kg/m2, median (range) Reduction of weight loss, median % (range) Reduction of excess weight, median % (range) Diabetes resolved, n (%) Hypertension resolved, n (%) Sleep apnea resolved, n (%) Hyperlipidemia resolved, n (%) Degenerative osteoarthritis resolved, n (%) Back pain resolved, n (%) Death, n (%) BAROS score, median score/9 (range)
21 52.2 31 36 69.7 3 13 27 6 10 6 0 7/9
(12–48) (50–87) (25–37) (28–56) (52–100) (60) (65) (90) (50) (45.4) (27.2) (0) (6–9)
BAROS ¼ bariatric analysis and reporting outcome system; BMI ¼ body mass index.
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acceptable safety profile. LSG using 4 to 7 skin incisions has been proposed as a primary bariatric procedure, even in high-risk patients, such as SOPs. The natural evolution of laparoscopy is toward reduction of the number of trocar sites for a procedure. In the era of minimally invasive surgery, the concept of single-incision laparoscopic surgery has been developed with the goal to minimize surgical trauma. SPSG requires less intra-abdominal space because the surgeon works in a small surgical corridor with less invasive surgery. Therefore, SPSG should also be of particular interest for SOPs who are at higher risk and are technically more difficult cases because the intra-abdominal space is limited by the intra-abdominal fat and increased thickness of the abdominal wall. We strongly believe that the natural evolution is from LSG to SPSG [20,21]. We report here the largest series of SPSGs for SOPs in routine bariatric clinical practice, showing the feasibility, reproducibility, efficacy, and, in this series, safety of this surgical procedure [14,15,21]. Median duration of surgery was 89 minutes, similar to classic laparoscopy for SOPs [22]. Additional trocars were required in 12 patients, and 8 were applied in the first 20 patients. When necessary, an epigastric trocar was added, mainly because of liver hypertrophy, which is a present in most SOPs [21]. In our series, we did not use a very-lowcalorie diet before surgery to reduce the size of the liver lobes [23,24]. The use of an additional epigastric trocar allowed better exposure, leading to reduction of operative time. Our complication rate was low (4.8%), including 2 cases of bleeding, which was diagnosed on postoperative CT and required repeat laparoscopy. An incisional hernia occurred in only 1 patient during the follow-up period. This low percentage probably resulted from the size of the single incision, which, despite is small size, offers a good view of the aponeurosis and allows a solid closure, even in the deep abdominal wall in SOPs [25]. Finally, this unique incision and the use of the single port allow easy extraction of the resected stomach without parietal contamination, thus facilitating a step that would be particularly hazardous in SOPs with the use of a 12-mm port. Median weight reduction was approximately 70%. This SPSG result in SOPs is better compared with those of conventional LSG reported in previous studies [26]. Most authors do not recommend the use of single-port access for SOPs, pointing out that abdominal fat and liver hypertrophy can make surgery difficult [20,27,28]. The use of a single port introduces 2 concepts that probably facilitate this approach in SOPs. The first concept is the “surgical corridor”: For the surgeon working in a small intraperitoneal area, the excess abdominal fat and liver hypertrophy are less problematic, partly because of the position of the instruments in the same axis. Sleeve gastrectomy is very interesting for single-port surgery because dissection and stapling are feasible in a small
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space, with a very stable axis and reduced exposure. In contrast, laparoscopic cholecystectomy requires a diverging exposure, making it very difficult to accomplish single-port cholecystectomy in routine practice. The second concept is the “parietal space”: This corresponds to the area in the abdominal wall through which the instruments are introduced. Preservation of this space depends on the position of the trocar, the size, and the number and axis of the instruments. In our series of SPSG patients, we experienced less conflict and clashing of the instruments when the incision was made in the left hypochondrium rather than in the umbilicus. This difference was more pronounced in SOPs. In fact, positioning of the single port in the left upper abdominal quadrant provides an optimal stapler axis, minimizing problems related to wall thickness and abdominal ptosis. To decrease conflict and clashing of the instruments, we routinely use a 5-mm double curved grasper, a laparoscope with a flexible tip or a 301 laparoscope with coaxial light. The larger instrument determinates the surgical axis. In addition, when positioned in the left upper quadrant, the left hand with the doublecurved grasper can lift the stomach and retract the liver upward by a rotating movement, allowing posterior gastric dissection in this limited space. As with all new procedures, a learning curve exists for SPSG. However, single-port surgery may have a less acute learning curve for surgeons well-experienced in conventional laparoscopic procedures. Similar technical challenges related to intra-abdominal access, camera angles, limited triangulation, instrument clashing, and coordination with the camera holder are faced in both conventional laparoscopy and single-port surgery. On the basis of our experience, we believe that SPSG in SOPs has a prolonged learning curve than for non-SOP patients. However, further studies in larger groups of patients are needed to draw definitive conclusions on this subject. Conclusion We have reported the largest series of SPSGs for SOPs in routine practice, showing the feasibility, safety, and efficacy of this technique in this specific population. We should not hesitate to add extra trocars should any technical difficulty arise. SPSG for SOP has to be performed in specialized centers, by bariatric surgeons well-experienced in both conventional laparoscopic surgery and single-incision surgery. Further prospective randomized studies have to performed to recommend SPSG for SOPs in routine practice. Disclosure The authors have no commercial associations that might be a conflict of interest in relation to this article.
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Original article
Single-port sleeve gastrectomy for super-obese patients Guillaume Pourcher, M.D.a,b,c,d, Stefano Ferretti, M.D.a,b, William Akakpo, M.D.a, Panagiotis Lainas, M.D., Ph.D.a,b,c,d, Hadrien Tranchart, M.D.a,b,c,d, Ibrahim Dagher, M.D., Ph.D.a,b,c,d a
Department of Minimally Invasive digestive Surgery, Hôpital Antoine Béclère, AP-HP, Clamart, France b Paris-Sud University, Kremlin-Bicêtre, France c Inserm, Unité 1193, Villejuif, France d DHU Hepatinov, Villejuif, France Received March 29, 2015; accepted December 1, 2015
Abstract
Background: Laparoscopic sleeve gastrectomy, which has become a primary bariatric procedure in super-obese patients (SOPs), is associated with considerable weight loss. Traditionally, laparoscopic sleeve gastrectomy requires 4–7 skin incisions. Single-port laparoscopic surgery is now feasible for bariatric surgery. Objectives: To evaluate the feasibility and safety of single-port sleeve gastrectomy (SPSG) for SOPs. Setting: Department of Abdominal and Minimally Invasive Surgery, Antoine Beclere Hospital, Assistance Publique-Hôpitaux de Paris, Paris-Sud University, France. Methods: Evaluation of the outcomes on patients who underwent surgery consecutively from June 2010 to June 2013 with follow-up of 41 year. Results: In total, 62 patients (46 women, 16 men) underwent SPSG. The median age was 41 years (range 19–67), median preoperative body mass index was 52.2 kg/m2 (range 50–87), median operative time was 89 minutes (range 42–212). Twelve patients required additional trocars, and 4.8 % developed complications. The median postoperative stay was 4 days (range 3–9 days) and median follow-up period was 21 months (range 12–48 months) with no loss of follow-up. The median percentage of excess weight loss was 69.7% (range 52%–100%) and percentage of weight loss was 36% (28%–56%) for the same period. Conclusion: SPSG for SOPs was found to be technically feasible, reproducible, and safe in this series. (Surg Obes Relat Dis 2016;12:522–527.) r 2016 Published by Elsevier Inc. on behalf of American Society for Metabolic and Bariatric Surgery.
Keywords:
Super-obese; Bariatric; Single port; Sleeve
Bariatric surgery is a widely accepted treatment for morbid obesity with very encouraging outcomes [1,2]. It induces long-term weight loss and leads to improvement or remission of associated diseases, such as type 2 diabetes mellitus and hypertension [1,3]. Laparoscopic sleeve gastrectomy (LSG) has become an established primary bariatric surgical technique, gaining popularity among surgeons during the last 5 years. LSG has an acceptable morbidity
and long-term weight loss results compared with the laparoscopic Roux-en-Y gastric bypass and adjustable gastric banding [4–6]. It is a relatively simple operation, thus being especially attractive for high-risk patients [7–9]. Recent studies have shown that male gender, advanced age, presence of multiple co-morbidities, and increased body mass index (BMI) are associated with higher morbidity and mortality rates in
http://dx.doi.org/10.1016/j.soard.2015.12.001 1550-7289/r 2016 Published by Elsevier Inc. on behalf of American Society for Metabolic and Bariatric Surgery.
SPSG for Super-obese Patients / Surgery for Obesity and Related Diseases 12 (2016) 522–527
bariatric surgery patients [10–12]. LSG has been used for super-obese patients (SOPs), defined by a BMI 450 kg/m2, providing satisfactory weight loss and the desired results [11,13]. Single-port laparoscopy has been shown to be safe and minimally invasive for performing a variety of abdominal procedures. The first single-port laparoscopic sleeve gastrectomy (SPSG) was described in 2008 by Saber et al. [14]. SPSG could also be of particular interest for high-risk patients, such as SOPs. However, only 2 studies have evaluated the operative and postoperative effects of SPSG on SOPs, with each study analyzing o10 patients [14,15]. The aim of this study was to report our experience of SPSG for SOPs in our series of consecutive patients. Patients and methods All SOPs (BMI 450 kg/m2) who underwent SPSG in our department from June 2010 to June 2013 were included in our study. The indications for bariatric surgery were in accordance with the French recommendations [16]. All patients underwent meticulous evaluation before surgery by a multidisciplinary team consisting of an endocrinologist, a gastroenterologist, a psychiatrist, a nutritionist, an anesthesiologist, and a surgeon. Appropriate preoperative investigations were performed, as indicated (esophagogastroduodenoscopy, upper gastrointestinal series, abdominal ultrasonography, polysomnography, and endocrinologic and nutritional evaluations). All patients were informed about the innovative nature of this technique and gave written informed consent before surgery, and the study was approved by the hospital institutional review board. Comorbidities were defined according to the international standard criteria (Table 1)—gastroesophageal reflux disease: need for proton pump inhibitor agents and/or esophagitis diagnosed on endoscopy and/or abnormal manometry; arthralgia: clinical and radiological findings. Remission and improvement of co-morbidities were defined by the endocrinologist/physician responsible for the followup. Remission was considered to have occurred when the value was normalized and improvement when the treatment was decreased.
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Operative technique Since the introduction of SPSG in our department, we have employed the same technique, as previously described [17]. Briefly, access is obtained through a 2- to 4-cm skin incision in the left upper quadrant, using an open technique for the introduction of the single port. The single-port device (Quad-Port, Olympus Medical, Nagano, Japan) consists of 2 ports of 5 mm, 1 port of 15 mm, and 2 ports of 12 mm. A 10-mm flexible tip laparoscope (LTF-VH or EndoEYE LS, Olympus Medical) or a 10-mm rigid co-axial 301 laparoscope is used. A double-curved nontraumatic grasper is used in the left hand for exposure, and a 5-mm thermofusion device (LigaSure, Covidien, France; or Thunderbeat, Olympus Medical) or the stapler in the right hand. The omentum is initially separated from the stomach, and the corpus is freed up to the left pillar of the diaphragm. This gastrolysis is obtained with the posterior dissection, section, and coagulation of the right gastro-omental vessels around the stomach and the short gastric vessels by using thermofusion grasper. When the angle of His is freed, the sleeve of the stomach is created over a 36-F bougie, after introduction of the orogastric tube along the lesser curvature, and transection of the stomach is done with the use of 60-mm endoscopic staplers, starting 6 to 7 cm proximal to the pylorus and heading toward the left side of the gastroesophageal junction. We use the same stapling over the stomach (Endo-GIA Tri-Staple by Covidien, Elancourt, France; or Echelon Flex powered by Ethicon, Issy-lesMoulineaux, France). For patients with a history of Lapband, we use a reinforced stapler (Perstrip by Baxter or Syngard by Gore). At the end of transection, the specimen is easily removed through the single port. The parietal wall incision is closed for all patients with 2 layers by using Vicryl 1. Then the skin is closed as usual with Vicryl fast 3/0. Drainage is not performed routinely but is only done in cases of particularly difficult gastric dissection. A urinary catheter or a nasogastric tube is never used. Postoperative management and follow-up In our study, abdominal computed tomography (CT) was routinely performed 2 days after surgery to rule out gastric
Table 1 International criteria defining the co-morbidities Co-morbidities
Definitions
Hypertension Type 2 diabetes
Systolic blood pressure 140 mm Hg or more and/or diastolic blood pressure Z90 mm Hg or antihypertensive drug therapy. On plasma glucose criteria, either the fasting plasma glucose (FPG), pathologic value is FPG 4126 mg/dL (7.0 mmol/L) or the 2-hour plasma glucose value 4200 mg/dL (11.1 mmol/L) after a 75-g oral glucose tolerance test. Recently, an International Expert Committee added the A1C (threshold Z6.5%) as a third option to diagnose type 2 diabetes Fasting high-density lipoprotein o40 mg/dL for men, o50 mg/dL for women, and/or triglycerides 4150 mg/dL and/or lowdensity lipoprotein 4100 mg/dL or the use of statins. Repeated upper airway occlusions during sleep with or without sleepiness and high apnea/hypopnea index and the need for continuous positive airway pressure during sleep.
Dyslipidemia Obstructive sleep apnea syndrome
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leak and hemorrhage/hematoma. Patients were evaluated by a dietary specialist at 15 days and 3 months after surgery. The surgeon followed up on the patients at 1, 3, and 6 months postoperatively. The dynamic result was assessed by a follow-up study of esophagogastroduodenal transit at 3 months and CT at 1 year. The efficacy of care was assessed by calculating the bariatric analysis and reporting outcome system score 1 year after surgery [18], and it was evaluated as a failure, fair, good, very good, or excellent [18]. Weight loss and remission of co-morbidities were assessed. Discontinuation of all medication for the treatment of a comorbidity was considered an indication of remission of the respective co-morbidity. Ninety percent of patients with sleep apnea discontinued continuous positive airway pressure use.
Co-morbidities were as follows : T2D in 8 patients (12.9%), hypertension in 30 patients (48.3%), obstructive sleep apnea syndrome in 45 patients (72.5%), hyperlipidemia in 18 patients (29%), degenerative osteoarthritis in 35 patients (56.4%), back pain in 37 patients (59.6%), thromboembolic disease in 6 patients (9.6%), coronary artery disease in 6 patients (9.6%), HIV infection in 3 patients (4.8%), and gastroesophageal reflux disease in 15 patients (24.1%). Twelve patients (19.3%) had previously undergone gastric banding. The gastric band was removed 3 months before SPSG in all patients. Five patients (8%) had previously undergone open surgery (3 cholecystectomies, 1 aortic surgery, and 1 emergency splenectomy).
Intraoperative and postoperative results Statistical analysis Data were prospectively gathered in an electronic database. Variables evaluated were duration of surgery, estimated blood loss, transfusion rate, number of stapler refills used, specific and general morbidity, perioperative mortality, postoperative pain medication requirement, and length of hospital stay. The statistical program Prism version 5.0 (GraphPad Software, La Jolla, CA) was used. Quantitative variables were expressed as mean (range) values, and qualitative variables were expressed as percentages. Results Sixty-two patients were included in our study (Table 2). Median age was 41 years (range 19–67 years) and 46 patients (74.1%) were women. Median weight was 140 kg (range 121–222 kg), with a median BMI of 52.2 kg/m2 (range 50–87 kg/m2). Table 2 Demographic characteristics of patients undergoing single-port sleeve gastrectomy in super-obese patients Patients
n ¼ 62
Age (yr): median (range) Female / male, n Weight (kg): median (range) Smoker, n (%) Body mass index, kg/m2 median (range) Co-morbidities Type 2 diabetes, n (%) Hypertension, n (%) Sleep apnea, n (%) Hyperlipidemia, n (%) Degenerative osteoarthritis, n (%) Back pain, n (%) Thromboembolic disease, n (%) Coronary artery disease, n (%) HIV infection, n (%) Gastroesphageal reflux disease, n (%) Previous gastric band, n (%) Open surgery, n (%)
41 (19–67) 46 / 16 140 (121–222) 7 (11.2) 52.2 (50–87) 8 30 45 18 35 37 6 6 3 15 12 5
(12.9) (48.3) (72.5) (29) (52.3) (59.6) (9.6) (9.6) (4.8) (24.1) (19.3) (8)
Detailed results are provided in Table 3. Median duration of surgery was 89 minutes (range 42–212 minutes). Intraoperative blood loss was minimal (range 0–20 mL), and postoperative bleeding required blood transfusion in 1 patient. All 62 SPSGs were performed without the need for conversion to open surgery. Twelve patients (19.3%) required additional trocars, 8 of them during the first 20 SPSGs. The additional 5-mm trocar was placed in the epigastrium to retract the left liver lobe in 8 patients. In 4 patients, additional trocars were used (∅5–12 mm) in the left hypochondrium for the introduction of the stapler because of conflict of the latter with the other instruments in the single port. Median number of stapler refills used was 5 (range 4–7 refills). The surgical specimen was removed intact through the single port in all cases without having to extend the incision. Table 3 Intraoperative and postoperative results following single-port sleeve gastrectomy in super-obese patients (n ¼ 62) Operating time (min): median (range) Blood loss (mL): median (range) Transfusion, n (%) Number of staplers cartridge/patient: median (range) Additional trocar
Conversion to open surgery, n (%) New surgery for complication Nasogastric or urinary tube, n (%) Analgesia, mg of morphine/kg: median (range) Realimentation (days): median (range) Complications, n (%)
Hospital stay (days): median (range) Death, n (%)
89 (42–212) o10 (0–20) 1 (1.6) 5 (4–7) For the 20 first patients (%) Total, n (%)
8 (40) 12 (19.3)
0 (0) 2 (3.2) 0 (0) 0.38 (0–1.4) 2 (2–3) Hemorrhage 2 (3.2) Leaks 0 (0) Other: (pneumopathy, 2 (3.2) incisional hernia) 4 (3–9) 0 (0)
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Two patients (3.2%) had postoperative complications and required surgical treatment on day 2, based on a control CT scan, and 1 of those patients had blood transfusion of 2 units of blood. In both cases, the patients experienced active bleeding, one from the left liver lobe and the other from the gastric staple line. One patient experienced pneumonia, which was successfully treated with antibiotics. No death occurred in the postoperative period. Median postoperative analgesia requirements were .38 mg/kg intravenous morphine sulfate equivalents (range 0–1.4 mg/kg). Median length of hospital stay was 4 days (range 3–9 days). Follow-up Median follow-up period was 21 months (range 12–48 months). The outcomes are summarized in Table 4. The majority of preoperative co-morbidities were found to have resolved during follow-up, including T2D in 60% of patients, hypertension in 65% of patients, obstructive sleep apnea syndrome in 90% of patients, hyperlipidemia in 50% of patients, hip and knee pain in 45% of patients, and back pain in 27% of patients. At least 1 co-morbidity disappeared for each patient. Mortality was nil during follow-up. One patient had an incisional hernia, which was treated 12 months later with surgical repair. Median reduction in excess weight was 69.7%, with all 62 patients losing 450% (range 52%–100%) of their excess weight. The median bariatric analysis and reporting outcome system score 1 year after surgery was 7/9. Discussion LSG provides various advantages, such as shorter duration of surgery, absence of gastrointestinal anastomosis and postoperative internal hernias, and lower incidence of vitamin deficiencies or malabsorption [5,19]. LSG is increasing in popularity, and in the medium-term followup, it is an effective weight loss procedure with an Table 4 Follow-up results after single-port sleeve gastrectomy in super-obese patients (n ¼ 62) Median follow-up, month (range) Preoperative BMI, kg/m2, median (range) Postoperative BMI, kg/m2, median (range) Reduction of weight loss, median % (range) Reduction of excess weight, median % (range) Diabetes resolved, n (%) Hypertension resolved, n (%) Sleep apnea resolved, n (%) Hyperlipidemia resolved, n (%) Degenerative osteoarthritis resolved, n (%) Back pain resolved, n (%) Death, n (%) BAROS score, median score/9 (range)
21 52.2 31 36 69.7 3 13 27 6 10 6 0 7/9
(12–48) (50–87) (25–37) (28–56) (52–100) (60) (65) (90) (50) (45.4) (27.2) (0) (6–9)
BAROS ¼ bariatric analysis and reporting outcome system; BMI ¼ body mass index.
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acceptable safety profile. LSG using 4 to 7 skin incisions has been proposed as a primary bariatric procedure, even in high-risk patients, such as SOPs. The natural evolution of laparoscopy is toward reduction of the number of trocar sites for a procedure. In the era of minimally invasive surgery, the concept of single-incision laparoscopic surgery has been developed with the goal to minimize surgical trauma. SPSG requires less intra-abdominal space because the surgeon works in a small surgical corridor with less invasive surgery. Therefore, SPSG should also be of particular interest for SOPs who are at higher risk and are technically more difficult cases because the intra-abdominal space is limited by the intra-abdominal fat and increased thickness of the abdominal wall. We strongly believe that the natural evolution is from LSG to SPSG [20,21]. We report here the largest series of SPSGs for SOPs in routine bariatric clinical practice, showing the feasibility, reproducibility, efficacy, and, in this series, safety of this surgical procedure [14,15,21]. Median duration of surgery was 89 minutes, similar to classic laparoscopy for SOPs [22]. Additional trocars were required in 12 patients, and 8 were applied in the first 20 patients. When necessary, an epigastric trocar was added, mainly because of liver hypertrophy, which is a present in most SOPs [21]. In our series, we did not use a very-lowcalorie diet before surgery to reduce the size of the liver lobes [23,24]. The use of an additional epigastric trocar allowed better exposure, leading to reduction of operative time. Our complication rate was low (4.8%), including 2 cases of bleeding, which was diagnosed on postoperative CT and required repeat laparoscopy. An incisional hernia occurred in only 1 patient during the follow-up period. This low percentage probably resulted from the size of the single incision, which, despite is small size, offers a good view of the aponeurosis and allows a solid closure, even in the deep abdominal wall in SOPs [25]. Finally, this unique incision and the use of the single port allow easy extraction of the resected stomach without parietal contamination, thus facilitating a step that would be particularly hazardous in SOPs with the use of a 12-mm port. Median weight reduction was approximately 70%. This SPSG result in SOPs is better compared with those of conventional LSG reported in previous studies [26]. Most authors do not recommend the use of single-port access for SOPs, pointing out that abdominal fat and liver hypertrophy can make surgery difficult [20,27,28]. The use of a single port introduces 2 concepts that probably facilitate this approach in SOPs. The first concept is the “surgical corridor”: For the surgeon working in a small intraperitoneal area, the excess abdominal fat and liver hypertrophy are less problematic, partly because of the position of the instruments in the same axis. Sleeve gastrectomy is very interesting for single-port surgery because dissection and stapling are feasible in a small
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space, with a very stable axis and reduced exposure. In contrast, laparoscopic cholecystectomy requires a diverging exposure, making it very difficult to accomplish single-port cholecystectomy in routine practice. The second concept is the “parietal space”: This corresponds to the area in the abdominal wall through which the instruments are introduced. Preservation of this space depends on the position of the trocar, the size, and the number and axis of the instruments. In our series of SPSG patients, we experienced less conflict and clashing of the instruments when the incision was made in the left hypochondrium rather than in the umbilicus. This difference was more pronounced in SOPs. In fact, positioning of the single port in the left upper abdominal quadrant provides an optimal stapler axis, minimizing problems related to wall thickness and abdominal ptosis. To decrease conflict and clashing of the instruments, we routinely use a 5-mm double curved grasper, a laparoscope with a flexible tip or a 301 laparoscope with coaxial light. The larger instrument determinates the surgical axis. In addition, when positioned in the left upper quadrant, the left hand with the doublecurved grasper can lift the stomach and retract the liver upward by a rotating movement, allowing posterior gastric dissection in this limited space. As with all new procedures, a learning curve exists for SPSG. However, single-port surgery may have a less acute learning curve for surgeons well-experienced in conventional laparoscopic procedures. Similar technical challenges related to intra-abdominal access, camera angles, limited triangulation, instrument clashing, and coordination with the camera holder are faced in both conventional laparoscopy and single-port surgery. On the basis of our experience, we believe that SPSG in SOPs has a prolonged learning curve than for non-SOP patients. However, further studies in larger groups of patients are needed to draw definitive conclusions on this subject. Conclusion We have reported the largest series of SPSGs for SOPs in routine practice, showing the feasibility, safety, and efficacy of this technique in this specific population. We should not hesitate to add extra trocars should any technical difficulty arise. SPSG for SOP has to be performed in specialized centers, by bariatric surgeons well-experienced in both conventional laparoscopic surgery and single-incision surgery. Further prospective randomized studies have to performed to recommend SPSG for SOPs in routine practice. Disclosure The authors have no commercial associations that might be a conflict of interest in relation to this article.
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