INTRODUCTION

Overweight and obesity are associated with multiple co-existing

conditions , including hypertension , glucose intolerance, dyslipidemia
and obstructive sleep apnea . Moreover , obesity is associated with an
increased risk of death from cardiovascular disease , diabetes , kidney
disease and obesity related cancers (colon , breast , esophagus , uterus ,
ovaries , kidneys and pancreas) ( Flegal et al , 2007 ) .
Medical therapies for obesity have been largely unsuccessful .
Currently, bariatric surgery provides the only effective option for weight
loss in morbidly obese individuals ( Snow et al , 2005 ) .
Because surgery currently offers the best chance to lose a
significant amount of weight , maintain the weight loss and improve the
quality of life, the number of bariatric procedures has risen exponentially
since the early 1990s ( Steinbrook , 2004 ) . The primary goal of bariatric
surgery is to induce sufficient weight loss to ameliorate obesity-related
co-morbidities such as diabetes, heart disease, hypertension and
obstructive sleep apnea (OBrien , 2002 ).
In recent years there has been renewed interest in the surgical
treatment of morbid obesity in concomitance with the epidemic of
obesity. Bariatric surgery proved effective in providing weight loss of
large magnitude, correction of co-morbidities and excellent short-term
and long-term outcomes, decreasing overall mortality and providing a
marked survival advantage. The Laparoscopic Sleeve Gastrectomy (LSG)
has increased in popularity and is currently very "trendy" among
laparoscopic surgeons involved in bariatric surgery (Ianelli A et al.,
.2008)

Laparoscopic sleeve gastrectomy (LSG) was first described as part

of biliopancreatic diversion with duodenal switch (BPD-DS) for the
treatment of super-obese high-risk patients with a body mass index (BMI)
>50 kg/m2, but results in terms of weight loss and resolution of comorbidities encouraged and stimulated the diffusion of sleeve
gastrectomy as a bariatric procedure per se. Laparoscopic sleeve
gastrectomy is technically quite a simple procedure involving resection of
80-90% of the stomach, leaving only a sleeve of stomach along the lesser
curvature (Casella et al., 2010).
The seducing potential of sleeve gastrectomy relies in the fact that
this operation is a straightforward procedure that can be generally
completed laparoscopically, even in the case of an extremely obese
patient . 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 , the whole digestive
tract remains accessible 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 not altered (Iannelli , 2006).

Vertical gastric placation is

a new procedure. The capacity of the
greater curvature into the lumen using

two rows of seromuscular sutures. The

stomach is thus converted into a tubular
structure that is based on the lesser
curvature without the need for resection of

Figure (1)

any part (Figure 1).

The operation proved its efficacy in animals (Fusco et al., 2006).

The first report on humans was made by Talebpour and Amoli in 2007.
They operated on a 100 cases and showed weight loss that is comparable
to other restrictive operations. This was followed by another report by
Ramos et al. in 2010. They operated on 42 patients and concluded that
laparoscopic gastric plication is feasible, safe, and effective for at least 18
months when performed on morbidly obese patients.
Pouch volume after bariatric surgery was found to correlate
positively with weight reduction (Roberts et al., 2007). The gastric
volume at the end of vertical gastric plication was estimated to be about
100ml (Talebpour et al., 2007), however they found that their patients
initially tolerated a maximum of about 50ml meals only. This was a rough
estimate and there are no previous attempts at monitoring any changes of
size as a result of pouch dilatation over time. Recently, CT volumetry
appeared as an accurate means of estimating the gastric capacity after
bariatric surgery (Karcz et al., 2009).

AIM OF WORK

The aim of this work is to compare short term changes in volume and
anatomy of the stomach following laparoscopic sleeve gastrectomy
versus laparoscopic gastric plication and comparing the effect of both
procedures on the clinical outcome and weight loss of the patients.

REVIEW OF LITERATURE
ANATOMY OF THE STOMACH
The stomach is readily recognizable as the asymmetrical, pearshaped, most proximal abdominal organ of the digestive tract (Fig. 2)
(Mercer et al., 2002). The part of the stomach attached to the esophagus
is called the cardia. Just proximal to the cardia at the gastro-esophageal
(GE) junction is the anatomically indistinct but physiologically
demonstrable lower esophageal sphincter. At the distal end, the pyloric
sphincter connects the stomach to the proximal duodenum. The stomach
is relatively fixed at these points, but the large mid-portion is quite
mobile (Ashley et al., 1999).

Figure 2

The superior-most part of the stomach is the distensible floppy

fundus, bounded superiorly by the diaphragm and laterally by the spleen.
The angle of His is where the fundus meets the left side of the GE
5

junction. Generally, the inferior extent of the fundus is considered to be

the horizontal plane of the GE junction, where the body (corpus) of the
stomach begins. The body of the stomach contains most of the parietal
(oxyntic) cells, some of which are also present in the cardia and fundus.
The body is bounded on the right by the relatively straight lesser
curvature

and on the left by the more curved greater curvature. At the

angularis incisura, the lesser curvature turns rather abruptly to the right,
marking the anatomic beginning of the antrum, which comprises the
distal 25 to 30% of the stomach (Ashley et al., 1999).

PHYSIOLOGY OF THE STOMACH

The stomach stores food and facilitates digestion through a variety
of secretory and motor functions. Important secretory functions include
the production of acid, pepsin, intrinsic factor, mucus, and a variety of
gastro-intestinal (GI) hormones. Important motor functions include food
storage (receptive relaxation and accommodation), grinding and mixing,
controlled emptying of ingested food, and periodic interprandial
"housekeeping" (Mercer et al., 2002).

Acid Secretion:
Hydrochloric acid in the stomach hastens both the physical and
(with pepsin) the biochemical breakdown of ingested food. In an acidic
environment, pepsin and acid facilitate proteolysis. Gastric acid also
inhibits the proliferation of ingested pathogens, which protects against
both infectious gastroenteritides and intestinal bacterial overgrowth.
Long-term acid suppression with proton pump inhibitors (PPIs) has been
associated with an increased risk of community acquired Clostridium
difficile colitis and other gastroenteritides, presumably because of the
absence of this protective germicidal barrier (Cadle et al., 2007).

Gastric Hormones:
Gastrin:
Gastrin is produced by antral G cells and is the major hormonal
stimulant of acid secretion during the gastric phase. Gastrin is also trophic
to GI epithelial and enterochromaffin cells. A variety of molecular forms
exist: big gastrin (34 amino acids; G34), little gastrin (17 amino acids;
G17), and minigastrin (14 amino acids; G14). The large majority of
gastrin released by the human antrum is G17. The biologically active
7

pentapeptide sequence at the C-terminal end of gastrin is identical to that

of CCK. Luminal peptides and amino acids are the most potent stimulants
of gastrin release, and luminal acid is the most potent inhibitor of gastrin
secretion. The latter effect is predominantly mediated in a paracrine
fashion by somatostatin released from antral D cells.
Gastrin-stimulated acid secretion is significantly blocked by H2
antagonists, suggesting that the principal mediator of gastrin-stimulated
acid production is histamine from mucosal enterochromaffin-like (ECL)
cells . In fact, chronic hypergastrinemia such as that seen with pernicious
anemia or long-term use of potent acid suppressants or gastrinoma is
associated with hyperplasia of gastric ECL cells and, rarely, gastric
carcinoid. Gastrin also is trophic to gastric parietal cells and to other GI
mucosal cells. Important causes of hypergastrinemia include pernicious
anemia, acid-suppressive medication, gastrinoma, retained antrum
following distal gastrectomy and Billroth II surgery, and vagotomy
(Johnson et al., 2006).

Somatostatin:
Somatostatin is produced by D cells located throughout the gastric
mucosa. The predominant form in humans is somatostatin 14, though
somatostatin 28 is present as well. The major stimulus for somatostatin
release is antral acidification; acetylcholine from vagal nerve fibers
inhibits its release. Somatostatin inhibits acid secretion from parietal cells
and gastrin release from G cells. It also decreases histamine release from
ECL cells. The proximity of the D cells to these target cells suggests that
the primary effect of somatostatin is mediated in a paracrine fashion, but
an endocrine (i.e., bloodstream) effect also is possible (Johnson et al.,
2006).

Gastrin-releasing peptide:
GRP is the mammalian equivalent of bombesin, a hormone
discovered more than two decades ago in an extract of skin from a frog.
In the antrum, GRP stimulates both gastrin and somatostatin release by
binding to receptors on the G and D cells. There are nerve terminals
ending near the mucosa in the gastric body and antrum, which are rich in
GRP immunoreactivity. When GRP is given peripherally, it stimulates
acid secretion, but when it is given centrally into the cerebral ventricles of
animals, it inhibits acid secretion, apparently via a pathway involving the
sympathetic nervous system. GRP is a mediator of gastroprotective
increased mucosal blood flow in response to luminal irritants (Del Valle
et al., 2003).

Leptin:
Leptin is a protein primarily synthesized in adipocytes. It is also
made by chief cells in the stomach, the main source of leptin in the GI
tract (Cummings et al., 2007). Leptin works at least in part via vagally
mediated pathways to decrease food intake in animals. Not surprisingly,
leptin, a satiety signal hormone, and ghrelin, a hunger signal hormone,
are both primarily synthesized in the stomach, an organ increasingly
recognized as central to the mechanisms of appetite control. (Badman et
al., 2007).

Ghrelin:
Ghrelin is secreted by the endocrine cells of the stomach (X/A-like
cells) which reside in the oxyntic glands of the gastric fundus. Gastric
ghrelin producing cells are in contact with the basement membrane
adjacent to the blood stream and most of them do not come in contact
9

with gastric content. The gastric fundus contains 10 to 20 times more

ghrelin per 1 gram of tissue than the duodenum with diminishing
concentrations being found in the jejunum and ileum (Neary et al.,
2004).
Ghrelin has been also found in different additional tissues in very
low concentrations such as the lungs, kidneys, pancreatic islets, gonads,
adrenal cortex, placenta and others (Van der Lely et al., 2004). Ghrelin
regulates the secretion of growth hormone release and is a potent
orexigenic (appetite-stimulating) peptide. This effect of ghrelin is
mediated

by

the

activation

of

ghrelin

receptors

in

the

hypothalamus/pituitary area (Sun et al., 2004).

There is some evidence that body weight is the major determinant
in the long-term regulation of the plasma concentration of ghrelin.
Accordingly, it has been shown that plasma concentration of ghrelin is
increased in the case of negative energy balance situations such as lowcalorie diets, chronic exercise, cancer anorexia, and anorexia nervosa and
are decreased in positive balance situations such as weight regain after
over-feeding, or during the weight recovery phase of anorexia nervosa or
in obese patients (Cummings et al., 2002) and (Otto et al ., 2001).
On the other hand, plasma concentration of ghrelin is acutely
regulated by the intake of food with a meal to meal variation. Plasma
ghrelin concentration rises just before the onset of meal and declines
thereafter suggesting that ghrelin could play a role in the signal of meal
initiation (Saad et al 2002).

10

Figure 3
Resection of the primary source of this hormone (i.e., the stomach)
may partly account for the anorexia and weight loss seen in some patients
following gastrectomy (Figure 3) (Ariyasu et al., 2001). The gastric
bypass operation, a very effective treatment for morbid obesity, has been
shown by some investigators to be associated with suppression of plasma
ghrelin levels (and appetite) in humans (Cummings et al., 2002). Other
groups have failed to show a significant decrease in ghrelin levels
following gastric bypass but have found such decreases following sleeve
gastrectomy, another effective weight loss operation (Karamanakos et
al., 2008). Obviously appetite control is complex with redundant and
overlapping

orexigenic

and

anorexigenic

pathways

(Cummings et al., 2007) and (Badman et al., 2005).

11

and

signals

Gastric Motility and Emptying:

Gastric motor function has several purposes. Interprandial motor
activity clears the stomach of undigested debris, sloughed cells, and
mucus. When feeding begins, the stomach relaxes to accommodate the
meal. Regulated motor activity then breaks down the food into small
particles and controls the output into the duodenum. The stomach
accomplishes these functions by coordinated smooth muscle relaxation
and contraction of the various gastric segments (proximal, distal, and
pyloric). Smooth muscle myoelectric potentials are translated into
muscular activity, which is modulated by extrinsic and intrinsic
innervation and hormones (Cummings et al., 2007) and (Badman et al.,
2005).

Gastric Emptying:
The control of gastric emptying is complex. In general, gastric
emptying is slowed by increasing caloric content or osmolarity, increased
fat content, and increased particle size; liquid emptying is faster than
solid emptying. Osmolarity, acidity, caloric content, and nutrient
composition are important modulators. Stimulation of duodenal
osmoreceptors, glucoreceptors, and pH receptors clearly inhibits gastric
emptying by a variety of neurohumoral mechanisms. Cholecystokinin
(CCK) has been consistently shown to inhibit gastric emptying at
physiologic doses. Recently, it has been noted that the anorexigenic
hormone leptin, secreted mostly by fat but also by gastric mucosa,
inhibits gastric emptying, perhaps through the same pathway as CCK
(which also has properties of a satiety hormone). The orexigenic hormone
ghrelin has the opposite effect (Wolfe et al., 1988).

12

Liquid Emptying:
The gastric emptying of water or isotonic saline follows first-order
kinetics, with a half emptying time around 12 minutes. Thus, if one
drinks 200 ml of water, about 100 ml enters the duodenum by 12 minutes,
whereas if one drinks 400 ml of water, about 200 ml enters the duodenum
by 12 minutes. This emptying pattern of liquids is modified considerably
as the caloric density, osmolarity, and nutrient composition of the liquid
changes. Up to an osmolarity of about 1 M, liquid emptying occurs at a
rate of about 200 kcal per hour. Duodenal osmoreceptors and hormones
(e.g., secretin and vasoactive intestinal peptide (VIP)) are important
modulators of liquid gastric emptying. Generally, liquid emptying is
delayed in the supine position (Feldman et al., 2002).
Traditionally, liquid emptying has been attributed to the activity of
the proximal stomach, but it is probably more complicated than
previously

thought.

Clearly,

receptive

relaxation

and

gastric

accommodation play a role in gastric emptying of liquids. Patients with a

denervated (e.g., vagotomized), resected, or plicated (e.g., fundoplication)
proximal stomach have decreased gastric compliance and may show
accelerated gastric emptying of liquids. A swallowed liquid meal induces
receptive relaxation, but the same meal delivered via nasogastric tube
bypasses this reflex and is associated with a higher intragastric pressure
and accelerated emptying (Feldman et al., 2002).
Some observations suggest an active role for the distal stomach in
liquid emptying. For instance even if the proximal intragastric pressure is
lower than duodenal pressure, normal gastric emptying of liquids can
occur. Also, diabetic patients may have normal proximal gastric motor
function and profoundly delayed gastric emptying of liquids. Indeed,
antral contractile activity does correlate with liquid gastric emptying, and
13

this distal gastric activity appears to vary with the nutrient composition
and caloric content of the liquid meal. Depending on the circumstances,
distal gastric motor activity can promote or inhibit gastric emptying of
liquids. Distal gastrectomy and pyloric stenting both obviously interfere
with distal gastric motor activity, and both accelerate the initial rapid
phase of liquid gastric emptying (Feldman et al., 2002).

Solid Emptying:
Normally, the half-time of solid gastric emptying is <2 hours.
Unlike liquids, which display an initial rapid phase followed by a slower
linear phase of emptying, solids have an initial lag phase during which
little emptying of solids occurs. It is during this phase that much of the
grinding and mixing occurs. A linear emptying phase follows, during
which the smaller particles are metered out to the duodenum. Solid
gastric emptying is a function of meal particle size, caloric content, and
composition (especially fat). When liquids and solids are ingested
together, the liquids empty first. Solids are stored in the fundus and
delivered to the distal stomach at constant rates for grinding. Liquids also
are sequestered in the fundus, but they appear to be readily delivered to
the distal stomach for early emptying. The larger the solid component of
the meal, the slower the liquid emptying. Patients bothered by dumping
syndrome are advised to limit the amount of liquid consumed with the
solid meal, taking advantage of this effect. Three prokinetic agents are
commonly used to treat delayed gastric emptying (Ashley et al., 1999).

14

DIAGNOSTIC TESTS
Esophagogastroduodenoscopy:
Esophagogastroduodenoscopy (EGD) is a safe and accurate
outpatient procedure performed under conscious sedation. Smaller
flexible scopes with excellent optics and a working channel are easily
passed transnasally in the unsedated patient. Following an 8-hour fast, the
flexible scope is advanced under direct vision into the esophagus,
stomach, and duodenum. The fundus and GE junction are inspected by
retroflexing the scope. To rule out cancer with a high degree of accuracy,
all patients with gastric ulcer diagnosed on upper GI series or found at
EGD should have multiple biopsies of the base and rim of the lesion.
Brush cytology also should be considered. Gastritis should be biopsied
both for histological examination and for a tissue urease test to rule out
the presence of H. pylori. If Helicobacter infection is detected, it should
probably be treated because of the etiologic association with peptic
ulcers, mucosa-associated lymphoid tissue (MALT), and gastric cancer.
The most serious complications of EGD are perforation (which is rare,
but can occur anywhere from the cervical esophagus to the duodenum),
aspiration, and respiratory depression from excessive sedation. Although
EGD is a more sensitive test than double-contrast upper GI series, these
modalities should be considered complementary rather than mutually
exclusive (Marks et al., 2007).

Radiological Tests:
Plain abdominal x-rays may be helpful in the diagnosis of gastric
perforation (pneumoperitoneum) or delayed gastric emptying (large airfluid level) (Harbison et al., 2005).

15

Double-contrast upper GI series may be better than EGD at

elucidating the following: diverticula, fistula, tortuosity or stricture
location, and size of hiatal hernia. Although there are radiologic
characteristics of ulcers that suggest the presence or absence of
malignancy, it must be reiterated that gastric ulcers require adequate
biopsy (Harbison et al., 2005).

Computed Tomographic Scanning And Magnetic Resonance

Imaging:
Most cases of significant gastric disease can be diagnosed without
these sophisticated imaging studies. However, one or the other should be
part of the routine staging work-up for most patients with a malignant
gastric tumor. Magnetic resonance imaging (MRI) may prove clinically
useful as a quantitative test for gastric emptying, and may even hold some
promise for the analysis of myoelectric derangements in patients with
gastroparesis. Advanced processing of high-resolution helical CT and
MRI data has made virtual endoscopy a reality. Currently a research tool,
it may have potential as a screening tool for gastric disease because it is
noninvasive and does not require a physician on site to perform. Digital
transmission allows the images to be analyzed remotely. In specialized
centers, impressive virtual endoscopic images are obtained with CT scan
or MRI. Of course suspicious lesions discovered by such techniques
require endoscopic evaluation. And, before screening at-risk populations
with these noninvasive modalities for gastric disease, the false-negative
rates would have to be shown to be acceptably low.
Arteriography rarely is necessary or useful in the diagnosis of
gastric disease. It may be helpful in the occasional poor-risk patient with
exsanguinating gastric hemorrhage, or in the patient with occult gastric
bleeding that is difficult to diagnose. Extravasation of contrast indicates
16

the location of the bleeding vessel, and embolization or selective infusion

of vasopressin may be therapeutic. Occasionally, empiric embolization of
the suspected but unproven bleeding vessel helps. Arteriovenous
malformations have a characteristic angiographic appearance (Shin et al.,
2007) and (Scheibl et al., 2005).

Endoscopic Ultrasound:
Endoscopic ultrasound (EUS) is useful in the evaluation and
management of some gastric lesions. Local staging of gastric
adenocarcinoma with EUS is quite accurate, and this modality can be
used to plan therapy. At some centers, patients with transmural and/or
node positive adenocarcinoma of the stomach are considered for
preoperative (neoadjuvant) chemoradiation therapy. EUS is the best way
to clinically stage these patients locoregionally. Suspicious nodes can be
sampled with EUS-guided endoscopic needle biopsy. Malignant tumors
that are confined to the mucosa on EUS may be amenable to endoscopic
mucosal resection (EMR). EUS also can be used to assess tumor response
to chemotherapy. Submucosal masses are commonly discovered during
routine EGD. Large submucosal masses should be resected because of the
risk of malignancy, but observation may be appropriate for some small
submucosal masses (e.g., lipoma or small gastro-intestinal stromal tumor
(GIST)). There are endoscopic characteristics of benign and malignant
mesenchymal tumors, and thus, EUS can provide reassurance, but no
guarantee, that small lesions under observation are probably benign.
Submucosal varices also can be assessed by EUS (Caddy et al., 2007).

17

Gastric Secretory Analysis:

Analysis of gastric acid output requires gastric intubation, and it is
performed infrequently nowadays. This test may be useful in the
evaluation of patients with hypergastrinemia, including the ZollingerEllison syndrome (ZES), patients with refractory ulcer or gastroesophageal reflux disease (GERD), and patients with recurrent ulcer after
operation. Historically, gastric analysis was performed most commonly to
test for the adequacy of vagotomy in postoperative patients with recurrent
or persistent ulcer. Now this can be done by assessing peripheral
pancreatic polypeptide levels in response to sham feeding. A 50%
increase in pancreatic polypeptide within 30 minutes of sham feeding
suggests vagal integrity. Gastric analysis is performed in the fasted state
with the semirecumbent patient in the left lateral position. After the
position of the nasogastric tube is verified, the tube is hand aspirated
every 5 minutes. Four successive 15-minute samples are created by
pooling 5-minute aliquots. An IV stimulant of acid secretion may then be
administered (typically pentagastrin) or, more commonly, the patient is
sham fed ("chew and spit"), and the process repeated. Samples are
analyzed by titration. Normal basal acid output (BAO) is <5 mEq/h.
Mean acid output (MAO) is the average of the two final stimulated 15minute periods and is usually 10 to 15 mEq/h. Peak acid output is defined
as the highest of the four stimulated periods. Patients with a gastrinoma
commonly have a high BAO, often above 30 mEq/h, but consistently
above 15 mEq/h unless there has been previous vagotomy or gastric
resection. In patients with gastrinoma, the ratio of BAO to MAO exceeds
0.6. Normal acid output in the patient prescribed acid-suppressive
medication usually means that the patient is noncompliant. To assess
acid-secretory capacity in the absence of medication effect, H2 blockers
18

and PPIs should be withheld for a week before gastric analysis (Balaji et
al., 2002).

Scintigraphy:
Nuclear medicine tests can be helpful in the evaluation of gastric
emptying and duodenogastric reflux. The standard scintigraphic
evaluation of gastric emptying involves the ingestion of a test meal with
one or two isotopes, and scanning the patient under a gamma camera. A
curve for liquid and solid emptying is plotted, and the half-time
calculated. Normal standards exist for each facility. Duodenogastric
reflux can be quantitated by the IV administration of hepatobiliary
iminodiacetic acid, which is concentrated and excreted by the liver into
the duodenum. Software allows a semiquantitative assessment of how
much of the isotope refluxes into the stomach. Positron emission
tomography (PET) scan or CT/PET scan may be useful in certain patients
with gastric malignancy (Chen et al., 2005).

Antroduodenal Motility Testing And Electrogastrography:

Antroduodenal motility testing and electrogastrography (EGG) are
performed in specialized centers and may be useful in the evaluation of
the patient with anomalous epigastric symptoms. EGG consists of the
transcutaneous recording of gastric myoelectric activity. Antroduodenal
motility testing is done with a tube placed transnasally or transorally into
the distal duodenum. There are pressure-recording sensors extending
from the stomach to the distal duodenum. The combination of these two
tests together with scintigraphy provides a thorough assessment of gastric
motility (Cullen et al., 1993).

19

PATHOPHYSIOLOGY OF MORBID OBESITY

Morbid Obesity is associated with a wide range of co-morbidities,
the most recognizable of which is type 2 diabetes & hypertension. The
presence of obesity increases the risk of type 2 diabetes in all age groups,
including children and adolescents with marked obesity (Sinha et al.,
2002).
Morbidly obese patients can be very resistant to insulin due to the
marked down-regulation of insulin receptors (Sugerman, 2003).
Obesity-associated hypertension is secondary to an increased intraabdominal pressure rather than to increased insulin-induced sodium
reabsorption. The presumed pathophysiology is related to activation of
the renin-angiotensin-aldosterone system (Valensi et al., 1996).
Activation of renin-angiotensin-aldosterone system leads to salt
and water retention, commonly seen in the severely obese. Surgically
associated weight loss is associated with a clinically significant, long
lasting

improvement

in

blood

pressure

with

elimination

of

antihypertensive medications in two- thirds to three- quarters of

hypertensive patients or a marked decrease in their use (Frigg et al.,
2004).
Morbid obesity may be also associated with cardiomegaly and
impaired left, right, or biventricular function (Kanoupakis et al., 2001),
Obesity hypoventilation syndrome (Sugerman, 1997), sleep apnea
syndrome (Guillemenault et al., 1986), venous stasis (Chan et al.,
1995), gastro-esophageal reflux disease (Rigaud et al., 1995), and many
other local & systemic diseases.

20

SURGERY FOR MORBID OBESITY

Indications :
According to the National Institute of Health (NIH) consensus and
the established criteria for bariatric surgery as expressed by the
International Federation of Surgery for Obesity (IFSO), to be eligible for
bariatric surgery a candidate must have a BMI >40, or >35 in the
presence of severe co-morbidity (Sugerman et al., 2003).
The candidate also should have attempted but failed at long-term
professional weight-reduction programs, including medication. The
option of surgical treatment should be offered only to a person who is
well informed and able to participate in treatment. A multidisciplinary
team should evaluate the candidate, and the operation should be
performed at a well-equipped medical center capable of managing all
types of surgical complications. This team also is responsible for
arranging the life-long follow-up program after surgery. At present, only
adults (>18 years) are accepted for bariatric surgery. However, morbid
obesity also affects adolescents, and some centers have performed
bariatric surgery on adolescents with favorable results (Stanford et al.,
2003).
The demand for bariatric surgery is rising worldwide. Increasing
awareness of the serious obesity-related morbidity by the general public
and health care professionals alike, along with continued improvement in
both the safety and long-term efficacy of the surgical procedures and the
introduction of laparoscopic surgical techniques, have contributed to the
boom in bariatric surgery (Nguyen, 2001).

21

There are three main types of surgical anti-obesity interventions:

physical or mechanical, regulatory (influencing appetite regulation), and a
combination of both physical and regulatory (Kral, 1998).
The main surgical principles involved are bypass of the intestinal
tract (resulting in malabsorption), restriction or obstruction of transit, and
neuroregulation that does not disrupt gastrointestinal continuity. Weight
loss due to surgical intervention alone has been found to range from 50
kg to 100 kg over a period of six months to one year (Mun et al., 2001).

Types :
Two primary strategies of surgically induced weight loss have
arisen over the past 50 years: gastric restriction and intestinal
malabsorption. Some procedures combine elements of restriction and
malabsorption. The restrictive procedures cause early satiety by creation
of a small gastric pouch and prolong satiety by creation of a small outlet
to that pouch. Restrictive procedures include many varieties of
gastroplasty and gastric banding. In these procedures, the outlet is
reinforced by prosthetic material to prevent dilatation. The pouch and the
outlet must be small enough to adequately restrict intake, yet not so small
as to cause obstruction. Adjustable gastric banding systems allow for fine
adjustment of the outlet diameter, which may offset the disadvantages of
a fixed nonadjustable outlet (Schauer and Ikramuddin, 2001).
Malabsorptive procedures in use today include the biliopancreatic
diversion (BPD), with or without duodenal switch, and the distal gastric
bypass (DGBP). These procedures involve some degree of gastric volume
reduction, but primarily depend on bypass of various lengths of small
intestine to cause malabsorption akin to a controlled short-gut
syndrome. The degree of malabsorption is determined by the length of

22

common channel where admixture of digestive enzymes occurs (Nguyen

et al., 2001).

Gastric Restriction:
Gastric restriction mechanically prevents the patient from
overeating by a mechanism similar to an hourglass. Satiety is caused by
creation of a small gastric pouch and prolonged by a small outlet, often
reinforced by prosthetic material to prevent dilation. They involve
surgical manipulation of the stomach only and thus are considered
straightforward from a technical standpoint. They also carry a low risk of
postoperative nutritional disturbances. Significant dietary compliance is
required because the intake of high-calorie liquids or soft foods is not
inhibited by the narrow outlet and will result in a failure to lose weight.
Gastric restrictive procedures sometimes require subsequent surgical
revisions due to failure (Mason, 1982).

Vertical Banded Gastroplasty:

Vertical banded gastroplasty (VBG) was 1 of the 2 operations
(along with Roux Y gastric bypass, RYGB) advocated in the 1991 NIH
consensus conference statement. In the late 1980s and early 1990s, it was
the most common surgical procedure for obesity but is now much less
common than gastric bypass. The VBG was first performed in 1980 by
Mason and reported in 1982 (Mason, 1982).
Since that time it has undergone several modifications. The
impetus for its development was observation of the common modes of
failure of horizontal gastroplasty including dilation of the proximal pouch
along the greater curvature and dilation of the stoma between the
proximal and distal stomach. The VBG improved on the horizontal
gastroplasty by using little of the greater curvature in its construction and
23

reinforcing the stoma with a nondistensible synthetic band. One popular

technique involves using a circular stapler to make a circular hole through
both the anterior and posterior gastric walls approximately 5 to 9 cm
distal to the gastroesophageal junction along a bougie placed into the
esophagus and stomach. A linear stapler is then used to perform a staple
line from the circular staple line to the angle of His. A nondistensible
band is then placed around the distal aspect of the neo-pouch typically
made of polypropylene mesh or a polypropylene suture wrapped with
dacron or silastic. This band acts to restrict the passage of food particles
and prevent long-term stoma dilation . The staple line may be
nontransected, transected (Figure 4), and in some techniques the fundus
of the stomach is removed.

Figure 4
Vertical Banded Gastroplasty

Laparoscopic VBG has been performed and can be accomplished

either completely laparoscopic or hand assisted (Lee et al., 2001).
24

As with horizontal gastroplasty, the VBG is a purely restrictive

operation in that digestion and absorption of nutrients are unaltered by the
surgery. All the weight loss effect comes from a reduction in calorie
intake. For most patients, the filling of the proximal pouch and slowed
transit through the banded stoma leads to a more rapid sense of satiety
and reduction of calorie intake without noxious symptoms. Unlike gastric
bypass, dumping syndrome does not occur with VBG; however, aversive
eating behavior certainly can occur with very large particle size foods,
which may obstruct the stoma and lead to epigastric pain, nausea, or
vomiting. Indeed, the relationship between stoma size, weight loss, and
aversive eating behavior is a complex one. An excessively small stoma
can lead to suboptimal weight loss because the excessive vomiting that
results from ingestion of solid foods leads patients to alter their food
choices in favor of high calorie liquid nutrients. Those patients who have
a baseline propensity to eat ice cream, milk shakes, or non-diet soda may
find this operation is less effective than the RYGB, since those foods are
generally well tolerated in VBG patients , but create dumping syndrome
after RYGB. There have been 5 randomized trials comparing the
outcomes of patients undergoing VBG with those of patients undergoing
RYGB. These have shown better weight loss effectiveness of RYGB with
similar perioperative and postoperative risks (Olbers et al., 2005).
Although some surgeons continue to perform the VBG in certain
patients their numbers are decreasing. In addition, the outcomes for VBG
are similar to the laparoscopic adjustable gastric band which is
technically easier to perform, likely has lower overall morbidity, and has
an adjustable stoma size. This has led to a shift toward the adjustable
gastric band as the restrictive procedure of choice. Nonetheless, there is
still a large population of patients with VBG anatomy who may develop
25

postoperative symptoms and seek surgical consultation (Kalfarentzos et

al., 2006).

Adjustable gastric banding:

Surgical attachment of a restrictive band decreasing the passage
into the stomach was developed as an easy, mechanical way to reduce
oral intake. Properly calibrating the outlet proved difficult at the time of
surgery however. If the band was too tight, the patient experienced
vomiting; too loose, and weight loss did not occur. These early attempts
stimulated the development of adjustable devices in the late 1980s
(Belachew et al., 1994). The technique of adjustable gastric banding
originated in 1982 when Szinicz and Schnapka placed a silicone band
around the upper stomach of rabbits. A balloon on the inner surface could
be inflated by way of a subcutaneous port, which would decrease the
inner diameter of the apparatus resulting in decreased passage of food
particles. This procedure was brought to the clinical realm by Dr.
Lubomyr Kuzmak, and he found that patients lost significantly more
weight than those patients who had non-adjustable bands placed
(Kuzmak, 1991). He then went on to design the first adjustable gastric
band for laparoscopic placement, which was first used by Dr. Guy
Bernard Cadiere in 1992.
The surgical procedure to place the laparoscopic adjustable gastric
banding (LAGB) is conceptually simple and consists of dissection of the
proximal stomach, band placement and fixation, and port placement. Due
to its simplicity, this can be achieved in the vast majority of patients
laparoscopically, although there is considerable variability in exact
procedures including patient positioning, port placement, and retraction.
There has been a shift in the technique of gastric dissection over the last
decade. Initially, dissection was most commonly made between the lesser
26

curve of the stomach and the left gastric artery along the gastric wall
entering the lesser sac and exiting at the angle of His. This so-called
perigastric technique has been associated with a higher rate of slippage of
the posterior wall of the stomach through the band (posterior slippage)
and is no longer recommended (Khoursheed et al., 2007).
The recommended technique is commonly called the pars
flaccida technique and initially involves dissecting the left lateral aspect
of the gastroesophageal pad of fat. The gastrohepatic membrane is then
opened visualizing the base of the right crus, and blunt dissection is made
through the retroperitoneal fat superiorly and to the left. This retrogastric
tunnel exits the retroperitoneal fat just posterior to the angle of His near
the superior pole of the spleen. Once the retrogastric tunnel is dissected, a
band of appropriate size is selected, inserted into the abdomen, and pulled
through the retrogastric tunnel. A buckling mechanism on the band is then
engaged. The fundus of the stomach is then plicated over the lateral
aspect of the band with 3 interrupted sutures to minimize the risk of
anterior band slippage, and the tubing is pulled through 1 of the
laparoscopic ports. The subcutaneous port is then attached to the tubing
and the port is fixed to the abdominal wall fascia in a position that will
facilitate future percutaneous access using a non-coring needle (Figure 5)
(OBrien et al., 2005).

27

Figure 5
Adjustable Gastric Banding

The mechanism of weight loss with the LAGB is believed to be

similar to the VBG and is purely restrictive. Commonly patients describe
a decrease in the sensation of hunger and/or earlier satiation during
ingestion of a meal, which tends to increase as the band is serially
tightened over the course of many months. As in patients with the VBG,
LAGB patients must refrain from ingestion of high calorie liquid meals to
obtain optimal weight loss, and they are susceptible to aversive eating
behaviors with large particle size foods, particularly as the band is
tightened further. The advantage of the LAGB comes from the ability to
make adjustments over time to the stoma diameter to find the optimum
balance between restriction of solid meal caloric intake and the avoidance
of maladaptive eating behaviors. Laparoscopic adjustable gastric banding
has been performed in increasing numbers since the Lap-Band system
(Allergan Inc., Irvine, CA, USA) gained FDA approval in 2001 (Ren et
al., 2000).
28

The benefits of the LAGB procedure include ease of placement,

adjustability, safety, and low rate of vitamin and mineral deficiency. The
Australian Safety and Efficacy Registrar of New Interventional
Procedures found that the peri-operative mortality rate for LAGB was 10
fold less than for gastric bypass (DeMaria et al., 2005).
Because of these benefits many patients and surgeons have come to
prefer the LAGB over gastric bypass. The track record for LAGB in
terms of longevity of weight loss and long-term complication profile are
less well studied than those for RYGB. Although most European and
Australian studies support the use of LAGB, outcomes in well designed
American studies have proved Equivocal (DeMaria et al., 2005).
The complication profile for LAGB is different than that for gastric
bypass or duodenal switch. The initial operation for LAGB may be
quicker, easier, and less risky than RYGB, but the long-term follow-up is
more intense, weight loss may not be as good, and long-term
complications are more common, but rarely life-threatening.
Although a validated algorithm for patient selection has not been
found outcomes with LAGB are likely more dependent on patient
selection and intense follow-up than other forms of bariatric surgery. It is
easier to cheat on the diet with an LAGB, and patients who are unable or
unwilling to change both their eating habits and exercise patterns will
have suboptimal weight loss. To optimize weight loss, patients must be
seen monthly for the first 12 to 24 months to determine the rate of weight
loss, satiety, and dysphagia. A properly adjusted band should provide
early and prolonged satiety with minimal to no dysphagia or regurgitation
There are concerns about reflux esophagitis, vomiting due to band
slippage, pouch dilation, and band erosions into the stomach. Long-term
follow-up has shown that the banding method is far from ideal. The
29

cumulative reoperation rate has been high, 10% Revisional operations

after band erosions are challenging from a technical standpoint and are
associated with high morbidity (Gustavsson and Westling., 2002).

Malabsorption:
Malabsorptive techniques involve creating a bypass of the small
intestine to produce a controlled short-bowel syndrome, causing
malabsorption of ingested nutrients and subsequent weight loss. Weight
reduction is reliable and superior to that of gastric restriction. However, a
higher risk of peri-operative complications and postoperative nutritional
deficiencies are inevitable consequences of these major rearrangements in
the anatomy and physiology of the upper gastrointestinal tract
(Scopinaro, 1979).

Roux-en-Y Gastric Bypass:

In the early 1970s, variants of the loop gastric bypass were first
performed using a Roux-Y limb to avoid alkaline reflux, and forms of
those operations persist today as the RYGB. Because of its combination
of persistent weight loss effectiveness and acceptable complication
profile, the RYGB is considered by many surgeons to be the gold
standard to which all other surgical procedures are compared. During the
late 1990s, the RYGB supplanted vertical banded gastroplasty and
became the most common procedure performed for obesity accounting
for up to 80% of bariatric procedures. The operation has been performed
both laparoscopic and open; however, the overall technique is the same.
The primary mechanism of weight loss is reduced calorie intake, although
macronutrient malabsorption may play a slight role in longer Roux limbs.
As with the loop gastric bypass, calorie reduction is due to a complex
effect on the sense of hunger and satiety due to reduced stomach
30

capacitance and adverse symptoms related to alterations in the transit of

ingested nutrients including dumping syndrome and possibly Roux-stasis
syndrome (Shikora, 2004).
The procedure consists of 3 basic steps: proximal pouch formation,
Roux limb formation, and gastrojejunostomy. Proximal pouch formation
entails forming a small gastric pouch (15-30 mL) either by transection of
the stomach or by occlusion with a stapling device (Figure 6). Over the
years, the pouch has tended to include less greater curvature and more
lesser curvature to prevent pouch dilation . There also has been a trend to
transect rather than simply occlude the stomach due to problems with
staple line recanalization. Buttressing of the staple line may increase burst
strength and possibly decrease bleeding of the constructed pouch.
Creation of the Roux limb involves transection of the jejunum 15 to 10
cm distal to the ligament of Treitz and end-to-side jejuno-jejunostomy 75
to 150 cm down the Roux limb. Thus ingested nutrients are not exposed
to bile and pancreatic enzymes until a point 90 to 250 cm distal to the
ligament of Treitz, and only a very small percentage of ingested nutrients
will be exposed to the duodenal mucosa via reflux up the proximal
jejunum. Some surgeons perform long limb bypass with Roux limb
segments being longer than 150 cm (Brolin, 2005).

31

Figure 6
Roux-en-Y Gastric Bypass

This effectively increases the component of weight loss due to

malabsorption. The Roux limb is brought up adjacent to the proximal
gastric pouch without tension. The orientation of the Roux limb
(antecolic, retrocolic, antegastric, retrogastric) is mainly determined by
surgeon preference. Our personal practice is to use a retrocolic,
retrogastric approach with 3 interrupted sutures fixing a consistent level
of the Roux limb circular muscle at the mesocolon defect and closure of
the Peterson hernia defect space superior to the edge of the Roux limb
32

mesentery. One concern about the ante-colic position is the potential for
increased tension at the gastrojejunostomy with resultant increased
ischemic stricture and possible leak rate (Bertucci et al., 2005).
This has not been shown to occur in retrospective studies, however,
the retrocolic path is shorter but requires creation of a transverse
mesocolic defect. One proposed benefit of the antecolic orientation is
lack of internal hernia formation through the transverse mesocolon
(Taylor et al., 2006).
Retrospective studies have shown that the antecolic position does
not protect against internal herniation due to hernias through the large
Peterson hernia defect space (Carmody et al., 2005).
The construction of the gastrojejunostomy is yet another area of
debate and again is likely more a matter of surgeon preference. Current
techniques include circular stapled, linear stapled, or completely
handsewn anastomoses. When the circular stapler is used, the anvil can
be introduced either by mouth or transabdominally. With the linear
stapled technique, the closure of the common enterotomy can be stapled
or handsewn. Again, there have been no randomized trials comparing any
of these techniques; however, there are studies to support each procedure
equally when considering operative time, leak rate, and stenosis (AbdelGalil et al., 2002).
One potential down side of the circular stapled technique is
increased risk of wound infection, which is reported to be as high as 10%.
It is believed that the rate of infection has been lowered by the use of a
laparoscopic entrapment sac to cover the end of the stapler before
removal as well as to house the transected small bowel segment for
removal (Podnos et al., 2003).

33

Other areas of controversy for the RYGB include drainage of the

gastrojejunostomy with the majority of surgeons preferring to leave
drains to monitor for a leak or early postoperative bleeding (Dallal et al.,
2007).
In addition, routine drainage can aid in treating an established leak
and will potentially obviate the need for re-exploration or percutaneous
drainage, which can be difficult in a morbidly obese patient. The routine
use and timing of radiologic gastrointestinal swallow studies has been an
area of contention as well. Many surgeons recommend a water-soluble
contrast study to evaluate for a leak before resumption of oral intake.
Early swallow studies can be misleading and falsely reassuring, and
patients may present with late leaks after a normal contrast study. A drain
is left to help detect early leaks and a water-soluble contrast study is
performed 1 week after operation to detect late leaks. (Madan et al.,
2007).
A variant of the RYGB is a combination of vertical banded
gastroplasty and gastric bypass, the so-called banded RYGB. The band is
placed in an effort to prevent the decrease in restriction that is seen in
some standard RYGB patients (Fobi, 2005).
Whether the risks of placement of a foreign body near the
anastomosis and persistent stomal diameter are counterbalanced by an
increase in effectiveness in long-term weight loss has yet to be
determined, but a randomized trial is currently under way to try to answer
this question (Bessler et al., 2007).

34

Biliopancreatic Diversion With and Without Duodenal

Switch:
Interest in the jejuno-ileal bypass (JIB) waned due to the excessive
number of complications, many of which were due to stasis in the
bypassed segment of jejunum. In the 1980s, an Italian surgeon, Dr. Nicola
Scopinaro championed the biliopancreatic diversion (BPD), an operation
that maintained much of the malabsorptive components of the JIB but
without the stasis in the bypassed segment. The BPD is still rare due to
perceived higher incidence of protein calorie malnutrition and fatsoluble
vitamin deficiencies, but the operation has been touted as an appropriate
procedure for those patients with supersuper morbid obesity (BMI > 60
kg/m2) (Marinari et al., 2004).
The operation entails a partial gastrectomy. The ileum is transected
250 cm above the ileocecal valve. Gastrointestinal continuity is restored
with a gastroileal anastomosis and an end-to-side ileoileostomy, creating
a 200-cm Roux limb and a 50-cm common channel. Stasis is avoided
since flow through the bypassed intestine includes bile and pancreatic
secretion, which is sufficient to avoid bacterial overgrowth and blind-loop
syndrome (Figure 7) (Scopinaro et al., 1996).
Patients lose a significant amount of weight due to the combination
of restriction from the gastrectomy, aversive eating behavior changes due
to dumping, and the malabsorption from the large amount of small bowel
bypassed. Additional reduction in hunger may also relate to hormonal
changes related to the delivery of calorie-rich enteric content directly into
the ileum, similar to the ileal brake known to slow gastric emptying . Dr.
Scopinaros results with the procedure are unsurpassed, with the average
patient losing 75% of their excess body weight, which is maintained for
35

more than 20 years. Additionally, the long-term complications from the

operation as reported by Dr. Scopinaro are uncommon and favorable
compared with many RYGB series. Anemia occurs in less than 5% of
patients when adequate folate and iron is given. Stomal ulcer occurs in
3% of patients in his series. Protein deficiency has been a serious concern
for those that perform this operation; however, Dr. Scopinaro has adapted
an individualized technique that adjusts the patients distal common
alimentary limb to limit this complication to less than 3% (Scopinaro et
al., 2007).
Concerned about the higher incidence of protein calorie
malnutrition and postgastrectomy complications of the BPD, North
American surgeons modified the BPD to increase the distal common
channel length and avoid ablation of the pylorus. The biliopancreatic
diversion with duodenal switch (BDP-DS) was first described by Hess
and colleagues in 1988 and simultaneously by Marceau and colleagues
and has been performed in selected centers over the last 19 years. The
operation differs from the BPD in that it includes a longer distal common
alimentary channel and a different type of gastrectomy. The gastrectomy
involves resection of the greater curve of the stomach with preservation
of the distal antrum, pylorus, and proximal duodenum. This portion of the
procedure is referred to as a sleeve gastrectomy and is commonly
performed over a 35- to 60-French bougie, leaving a maximal gastric
reservoir of 150 to 200 ml. The Roux limb is constructed with a 100-cm
distal common channel and a 150-cm Roux limb, which is anastomosed
end-to-end with the proximal cut end of the duodenum (Hess and
Oakley, 2005).
Weight loss occurs through a combination of restriction and
malabsorption By keeping the stomach and pylorus in continuity there is
36

diminished diarrhea, dumping syndrome, and ulcerogenicity. The 100-cm

common channel is felt to help limit the amount of protein malnutrition
(Marceau , 1998).
Very long limb RYGB with a distal common channel of 100 cm or
less may have a similar profile of malabsorption and some surgeons
perform this in supersuper morbidly obese patients . Biliopancreatic
diversion, with or without duodenal switch, has been performed totally
laparoscopically . Due to the multiplicity of enteric transactions and
anastomoses in multiple regions of the abdomen and the body habitus of
these patients, these are among the most difficult of laparoscopic
procedures. Therefore, this operation should only be performed by highly
skilled laparoscopic surgeons who are familiar with the open operation.
In addition, only surgeons who have adequate knowledge of the nutrient
deficiencies and metabolic consequences of this procedure should
perform this operation (Kim et al., 2003).
RYGBP has both restrictive and malabsorptive components. In the
1960s Mason observed that most patients lost weight after gastric
resection (Billroth II), and he subsequently developed a gastric bypass
technique for weight-loss surgery (Edwards et al., 2007).
In Masons original procedure the major part of the stomach was
bypassed by a jejunal loop to produce early satiety and weight loss . The
procedure has been altered and improved over the years to eliminate
different drawbacks. Currently, the RYGBP is the technique of choice
(Bertucci et al., 2005).
In this procedure, the stomach is divided into a small proximal
gastric pouch and the remaining main stomach is bypassed. The small
pouch is connected to the small bowel by a jejunal segment, a Roux limb.

37

In 1993, the operation was adapted to laparoscopy by Wittgrove and

Clark (Taylor et al., 2006).
This has increased its popularity, making RYGBP the most
performed bariatric procedure worldwide today. The long-term results are
good and most co-morbid conditions resolve. RYGBP is in addition well
tolerated by patients because they can eat normal foods. Moreover,
RYGBP is very durable as a revisional procedure after failed gastric
restriction. Iron, vitamin B12, folic acid and fat-soluble vitamin A, D, and
E deficiencies can occur. To overcome this, vitamin B12 is prescribed to
all patients and iron to menstruating women and encourage all patients to
take multivitamins daily (Quebbemann et al., 2005).
In Abdel Galils series, BMI is reduced from 46 to 30 at 1 year and
drops to 27 in the second year. At 5 years weight regain can be seen,
probably as a result of nibbling high-fat, energy dense foods. Long-time
follow-up has shown an average excess weight loss of 60% at 5 years and
47% at 14 years (Abdel Galil and Sabry, 2002).
The unknown fate of the bypassed segments is a potential
drawback. The excluded stomach and entire duodenum are not readily
available for radiographic or endoscopic examinations and most patients
are young at the time of surgery. Thus, ulcers and malignancies could
develop unnoticed in the excluded stomach over a long period. Attempts
to investigate the excluded stomach have, however, showed no
ulcerogenic potential or tendency of dysplastic mucosal development
during the first 4 postoperative years (Fisher et al., 2007).
Due to the high level of concern about the excluded stomach some
centers resect the whole stomach, instead of just bypassing it, at the
primary operation (Korenkov et al., 2003).

38

Figure 7
Bilio-pancreatic diversion

Evolution of Sleeve Gastrectomy:

Historically, surgical strategies for weight loss have focused on
stomach volume restriction, malabsorption of ingested nutrients, or both.
However, recent studies have questioned the real contribution of
restrictive or malabsorptive mechanisms, in part, due to an increased
understanding of body weight control pathways involving multiple
peptides (Wynne et al., 2004). Sleeve gastrectomy (SG) was introduced
as a promising bariatric operation. SG involves removing the fundus and
greater curvature portion of the stomach, leaving only a lesser curvature
tube (Deitel et al., 2007).

SG was initially described as a first-step procedure followed by either

biliopancreatic diversion with duodenal switch (BPD-DS) or Roux-en-Y

39

gastric bypass (RYGBP) in super-super obese patients, body mass index

(BMI) >60 kg/m2 or in high-risk patients (Almogy et al., 2004).
More recently, SG has been indicated as a definitive treatment in
patients with BMI >40 kg/m2 or BMI >35 kg/m2 associated with
comorbidities, and it has also been proposed for patients with moderate
obesity BMI <35 kg/m2 and metabolic syndrome (Tucker et al., 2008).
SG can be performed by an open laparotomy procedure but is
usually done as a laparoscopic operation [laparoscopic sleeve
gastrectomy (LSG)] which is particularly appropriate for the SG (Gumbs
et al., 2007).
Because of the relative technical ease of performance compared to
other bariatric procedures, acceptable operative time, low complication
rate and reports of average excess weight loss of 5183% at 1 year with
improvement in co-morbidity, many began to consider LSG as a primary
single-stage restrictive procedure (Moon et al., 2005).
Sleeve gastrectomy, as a primary operation in the management of
morbid obesity, was first reported in 2003. In that study, supersuperobese
patients underwent a laparoscopic SG followed by a second-stage
laparoscopic roux-en-Y gastric bypass (LRYGB). The mean preoperative
body mass index (BMI) was 63 and the average percent excess weight
loss (EWL) was 33 after 11 months (Catheline et al.,2006).
One of the mechanisms involved in weight loss observed after
sleeve gastrectomy is the dramatic reduction of the capacity of the
stomach. The concept of restriction has been widely used in bariatric
surgery in (VBG) and (LAGB). The distension of the small gastric pouch
is supposed to account for the feeling of early fullness, enhanced satiety

40

and decreased hunger experienced by a patient after the ingestion of small

quantities of food (Baltasar et al., 2005).

Evolution of Gastric Plication:

Laparoscopic gastric placation (LGP) is a new bariatric restrictive
procedure that avoids the complications linked with the permanent
implant of an adjustable gastric ring (oesophageal laceration, gastric
erosion) while also minimizing the possibility of leaks associated with
sleeve gastrectomy. Also known as gastric imbrication and total vertical
sleeve plication, the procedure consists of reducing the gastric volume by
placing at least two rows of nonabsorbable sutures on the greater gastric
curvature (Puia et al., 2011). Having as forerunners an open technique
tried in 1968 (Kirk, 1968) and the StomaphyX (Mikami et al., 2010)
device used in reducing a large stomach pouch after unsatisfactory
bariatric procedures, LGP was first described in 2007 by Talebpour et al.
Trials were initiated in the USA in 2009 and the first paper was published
in 2010 (Ramos et al., 2010).

Technique of Sleeve Gastrectomy:

Sleeve gastrectomy involves a longitudinal resection of the
stomach on the greater curvature from the antrum starting opposite of the
nerve of Latarjet up to the angle of His. The first step of the procedure is
the division of the vascular supply of the greater curvature of the
stomach, which is achieved with the section of the gastro-colic and
gastro-splenic ligaments close to the stomach. The greater curvature must
be completely freed up to the left crus of the diaphragm to completely
resect the gastric fundus that harbours the ghrelin secreting cells of the
stomach. The second step of the procedure is the longitudinal

41

gastrectomy that sleeves the stomach to reduce it to a narrow tube

(Figure 8) (Regan et al., 2003).

Figure 8

LSG is performed for morbid obesity with the patient in the supine
position on a split-leg operating table. The surgeon stands between the
42

patients legs with the first and second assistants on the patients right and
left sides, respectively (Figure 9). Under general anesthesia, the
procedure is begun with open entry into the abdomen through an incision
at the umbilicus. A 5- to 12-mm port is placed and pneumoperitoneum is
achieved with carbon dioxide to 15 mm Hg. Six additional ports are
placed under direct vision a 5- to 12-mm port is placed in the right upper
quadrant for liver retraction and an additional (optional) 5- to 12-mm port
is placed in the midepigastrium for visualization of the hiatus. Two 15mm disposable working ports are placed in the right and left
midepigastrium and a 5- to 12-mm disposable working port is placed in
the high epigastrium. Finally, a 5-mm reusable port is placed in the left
lower quadrant for lateral gastric retraction.
In steep reverse Trendelenburg position, dissection begins with
opening of the greater omentum using an ultrasonic dissector (Harmonic;
Ethicon Endosurgery, Cincinnati, OH, USA) or Ligasure (Autosuture
Bariatrics/Covidien) along the greater curvature of the stomach
approximately 4 to 6 cm proximal to the pylorus. The dissection
continues cephalad to the gastroesophageal junction and the left crus. The
short gastric vessels are ligated carefully and care is taken to avoid injury
to the spleen.
The left crus is completely freed of any attachments to avoid
leaving a posterior pouch when constructing the sleeve in this region. The
dissection is completed by freeing any posterior attachments of the
stomach to the pancreas. This is performed with sharp dissection to avoid
thermal injury to the pancreas or the lesser curvature of the stomach.
Gastric transection begins 4 to 6 cm proximal to the pylorus
(Figure

9). A 60-mm,

4.8-mm,

43

endo-GIA stapler

(Autosuture

Bariatrics/Covidien) is placed across the antrum through the right

midepigastric port and fired (Johnston et al., 2003).
The 4.8-mm staple height is used for the entire gastric transaction
because it is believed that it provides optimal tissue approximation
throughout the variable thickness of the stomach. The second stapler is
placed approximately 1 to 2 cm from the border of the lesser curvature in
the direction of the gastroesophageal junction. This stapler is fired only
after passage of a 40 F Maloney-type bougie (Medovation, Germantown,
WI, USA) through the esophagus and stomach and into the pylorus
aligned along the lesser curvature. The bougie must be held in this
position until completion of the stomach transection to avoid stapling
across a displaced bougie.

Figure 9
Sequential firings of the stapler along the border of the bougie on
the lesser curvature completes the gastric transection at the left crus. After
completing the transection, the entire staple line is inspected carefully to
44

make sure that the staples are well formed especially at the antrum where
the stomach is thickest. The transected stomach then is removed using a
specimen collection bag (EndoCatch; Autosuture Bariatrics/Covidien)
placed through one of the 15-mm port sites or by enlarging the umbilical
incision. After completion of the gastric transection the integrity of the
staple line is tested. The pylorus is compressed with a surgical grasper.
Methylene blue is injected into the stomach (throught the bougie) and the
staple line is inspected carefully for leak. The methylene blue then is
removed from the stomach, as is the bougie. All trocar sites are closed
with 0 Vicryl (Ethicon) using a suture passer to prevent abdominal wall
hernias (Almogy et al., 2004).

Technique of Gastric Plication:

All surgical procedures took place under general anesthesia with
the patient in supine position (legs open). Trocar placement was as
follows: one 10-mm trocar above and slightly to the right of the
umbilicus for the 30 laparoscope; one 10-mm trocar in the upper right
quadrant (URQ) for passing the needle, for suturing, and for the surgeons
right hand; one 5-mm trocar also in the URQ below the 10-mm trocar at
the axillary line for the surgeons assistant; one 5-mm trocar below the
xiphoid appendices for liver retraction; and one 5-mm trocar in the upper
left quadrant (ULQ) for the surgeons left hand (Figure 10). The
procedure began with the dissection of the Angle of His and the removal
of the pad of fat in this location, followed by careful dissection of the
gastric greater curvature using the Harmonic scalpel and opening the
greater omentum at the transition between the gastric antrum and gastric
body. Once access to the posterior wall was achieved, the greater
curvature vessels were dissected distally up to the pylorus and proximally
up to the Angle of His. Occasionally, posterior gastric adhesions were
45

also dissected to allow optimal freedom for creating and sizing the
invagination properly. The next step was to initiate gastric plication by
imbricating the greater curvature over a 32-Fr bougie and applying a first
row of extra-mucosal interrupted stitches of 2-0 Ethibond sutures
(Figure 11). This row guided two subsequent rows created with extramucosal running suture lines of 2-0 Prolene. The reduction resulted in
a stomach shaped like a large sleeve gastrectomy (Ramos et al., 2010).

Figure 10
Fig. 1 Trocar position: a. 10mm above the umbilicus slightly to the
right; b. 10mm in URQ; c. 5mm below xiphoid's appendices; d. 5mm
in the ULQ; e. 5mm on the URQ at the axilary line (Ramos et al., 2010)

46

Figure 11

Advantages of Sleeve:
As the global population continues to suffer from increasing
obesity, surgeons have begun devising safer methods for the management
of these patients. By performing less invasive procedures as the initial
part of a two-staged surgical regimen, complications and mortality can be
kept to a minimum (Nguyen et al., 2005). Some surgeons have begun
using SG as solitary therapy for the treatment of morbid obesity. This is
because of the lack of need for foreign material, excellent patient
tolerance by maintenance of gastric emptying, and decreased incidence of
nutritional deficiencies (Catheline et al., 2006).
A study of 23 patients, not included in this analysis, found that
after SG, stomach contents actually empty rapidly into the small
intestines casting doubt as to whether this procedure is truly restrictive
and underscoring the possibility that gut hormonal alterations may play a
larger role in satiety and weight loss than currently appreciated (Melissas
et al., 2007).

SG is an excellent procedure for the surgical management of

morbid obesity. EWL at 6 and 12 months averages 49% and 56%,
respectively (Mognol et al., 2005).
47

Improvement in co-morbidities of obesity, such as hypertension

and diabetes mellitus, has been reported to occur in the majority of
patients with resolution in 60-100% When compared to other restrictive
procedures, the removal of the greater curvature of the stomach may
result in decreased risk of gastric dilation and the removal of ghrelin
producing stomach mass may result in better long-term weight loss
(Cottam et al., 2006).
This operation has a low incidence of complications and mortality,
and is particularly useful in the superobese who may benefit from a
twostaged procedure. Although SG may be effective treatment for morbid
obesity up to 2 years after surgery, longer term studies (>5 years) are
necessary to determine whether SG is a durable procedure in the
treatment of morbid obesity (Lee et al., 2006).
Mognol and coworkers performed LSG in 10 patients with a BMI
of more than 60 kg/m2. They reported no conversions, no morbidities, and
no mortalities. EWL, after 1 year, was 51%. They concluded that LSG
was an appropriate first-step procedure and an acceptable one-stage
restrictive procedure if long-term results were good (Mognol et al.,
2005).
LSG is not exempt from complications, and inadequate weight loss
or weight regain is theoretically more likely with operations which do not
induce malabsorption. However, sleeve gastrectomy can later be
converted to RYGBP or DS. Patients with higher BMI may require a
second-stage operation later, in order to lose the rest of their excess
weight if their BMI remains >45. LSG is not a reversible procedure
because stomach is resected, and finally the longterm results are at this
moment unknown (Milone et al., 2005).

48

In conclusion, sleeve gastrectomy could be an alternative bariatric

operation, easy to perform, safe, with less complications than other
bariatric operations. However, further technical studies must be
performed and long-term follow-up is awaited. Baltasar in Spain, Gagner
is USA, Han in Asia and Catheline in France have reported that this
operation is successful for these types of patients The results published up
to now are very promising in terms of decrease in weight, decrease in
BMI, and a very satisfactory EWL with improvement of comorbidities
(Regan et al., 2003).

Advantages of Plication:
Laparoscopic Gastric Plication is a bariatric procedure that brings
together the benefits of food restriction without the possible
complications associated with a permanent implant while also
minimizing the possibility of leaks from the rupture of staple lines is
highly desirable and may be a preferred alternative restrictive procedure
for some patients. LGCP is notably similar to a VSG in that it generates a
gastric tube by means of eliminating the greater curvature but does so
without gastric resection. It is likely that LGCP greatly reduces the
possibility for gastric leaks. Talebpour and Amoli report one case of a
gastric leak associated with a more aggressive version of LGCP, which
the authors attributed to excessive vomiting in the early postoperative
period (Ramos et al., 2010).
A paper in 2010 reported efficacy in gastric plication procedures,
as measured by changes in the weight progression of rats (Fusco et al.,
2010). Fusco et al. reported an increased effect from plication of the
greater curvature when compared to plication of the anterior surface.
Other clinical reports were done in 2009 and reported an increased weight

49

loss in patients receiving LGCP when compared to plication of the

anterior surface (Brethauer et al., 2009).

Expected problems & Complications of Sleeve:

Gumbs and co-workers reported the incidence of complications
among the published articles including 646 patients who underwent SG
(Gumbs et al., 2007).
Morbidities included reoperation (4.5%), leak (0.9%), strictures
(0.7%), postoperative bleeding (0.3%), pulmonary embolism (0.3%),
delayed gastric emptying (0.3%), intraabdominal abscess (0.1%), wound
infection (0.1%), splenic injury (0.1%), and trocar site hernia (0.1%).
Four mortalities were reported (0.6%). These data suggest the safety of
SG as a bariatric procedure; however, long-term data from prospective
trials are lacking (Moon et al., 2005).
A large retrospective series of 146 patients was recently published
by Lalor et al. looking at SG as a single-stage operation proved the
efficacy and safety of this procedure . Mean age of the enrolled subjects
was 47 years with BMI of 44 kg/m2; the reported complications
comprised gastric leak (0.7%), abscess (0.7%), bleeding (0.7%), stricture
(0.7%), and late choledocholithiasis (0.7%) (Lalor et al., 2008).
SG was proposed to have an adverse effect on the function of the
lower esophageal sphincter (LES) due to gastric resection at the angle of
His predisposing the patient to postoperative reflux symptoms. Himpens
et al. showed GERD incidence of 21.8% at 1-year follow-up with
subjective improvement of the symptoms (3.1%) at 3-year follow-up
(Klaus and Weiss., 2008) and (Himpens et al., 2006).
On the contrary, Melissas et al. showed that gastric emptying is
accelerated after SG, a physiological change that might play a beneficial
50

role to improve GERD symptoms. To date, there are no objective

manometric studies of the LES function and esophageal motility before
and after SG to correlate GERD and SG (Melissas et al., 2007).

Complications after SG:

Recent data has shown good results in patients with BMI less than
50. However, all the published studies have a short-term(1 year) followup period. It has been evident that a subgroup of patients do regain weight
after the year, and the authors speculate that this proportion will rise with
a longer follow-up. Dilatation may be the first cause of failure (Gagner
and Rogula, 2003).
It may be a result of an excessively large pouch being created at the
initial operation because of missed posterior gastric folds. Excessive
pressure against the pouch walls by large meals, repeated vomiting, or
distal obstruction leads to its dilatation. Increasing proximal pouch
diameter may also be a result of hiatal hernia, missed preoperatively or
intraoperatively (Deitel, 2000).
An adequate patient selection and appropriate surgical technique
may not prevent pouch dilatation. The pouch expansion may be
controlled by external wrapping or with an external silastic ring support,
as proposed by Fobi and coworkers, in gastric bypass (Fobi, 2005).
It is unlikely that a laparoscopic adjustable gastric banding will be
useful to prevent gastric dilatation, because it is a known frequent
complication of this method and when used in super-obese patients, a
lesser percent of EWL is achieved at 1 year. The subgroup of patients
with a BMI more than 50 kg/m2 have had less EWL than those with a
lower BMI. Most of these patients require a second-stage procedure to
assure weight control (Dolan et al., 2004).
51

Clinical follow-up of LGP:

In the postoperative period, patients were discharged as soon as
they accepted a liquid diet without vomiting and received a prescription
of a daily proton-pump inhibitor (PPI; single dose) for 60 days.
Ondasentron and the anti-spasmodic hyoscine were prescribed for 7 days.
The postoperative diet was prescribed as follows: a customized liquid diet
for 2 weeks, followed by a progressive return to solid foods in a stepwise
fashion, with the dietary restrictions removed at 4 to 6 weeks, depending
on patient acceptance. Follow-up visits for the assessment of safety and
weight loss were scheduled for 1 week and at 1, 3, 6, 12, 18, and 24
months in the postoperative period. Endoscopic evaluations were
scheduled for 1, 6, and 12 months (Ramos et al., 2010).
Nausea, vomiting and sialorrhea may affect up to one third of the
patients during the first two weeks (Talebpour and Amoli, 2007). A
liquid diet is started as soon as it can be tolerated, gradually switching to
solid food after two weeks. Proton pump inhibitors are recommended for
60 days. Follow-up visits should be scheduled after 1 week, 1, 3, 6, 12
and 18 months (Puia et al., 2011).
Upper endoscopy or barium swallow are not mandatory, unless
symptoms of reflux are present. The imbricated gastric fold is smaller at 6
months compared with the evaluation at 1 month and remains unchanged
after a longer period. The lumen size appears also unaffected by dilation
(Talebpour and Amoli, 2007).

52

VOLUMETRY OF THE STOMACH

History:
Since 1968 or even before that date, several techniques were
invented for measurement of the volume of the stomach. J. D. George
described a technique called the 'double sampling test meal' where he
used phenol red as a dye, based on a mathematical principle that is a bit
complex: The volume of fluid in a container can be ascertained by
determining the increase in concentration of a dye produced by the
addition of a small concentrated measure of the same dye (George,
1968). Since then, several studies were conducted to evaluate gastric
capacity, volume & accommodation.

1.Balloon Measurements:
The gold standard for the measurement of tone in hollow organs
remains the barostat, which estimates changes in tone by the change of
volume of air in an infinitely compliant balloon maintained at a constant
pressure (Azpiroz and Malagelada, 1985). A variant is the tensostat,
which corrects, in real time, for the changes in volume or diameter of the
balloon to estimate luminal wall tension on the basis of the Laplace law
(Corsetti et al., 2004 & Distrutti et al., 1999).
One measurement of gastric capacity used a latex balloon, with a
capacity of ~1 liter attached to a double-lumen tube, passed orally into
the stomach. A pump, placed behind the subject, was used to fill the
balloon with water at a rate of 100 ml per min, with 1-min pauses to
record pressure, through a second lumen. The compliance of the balloon
in vitro was subtracted from the measured intragastric pressure. With
each 100 ml, abdominal discomfort was rated on a 0100 scale. The
53

result of gastric volume was based on the maximum tolerated volume and
the volume to produce a 5-cm water rise in intragastric pressure
(Geliebter et al., 2004).
Pitfalls in these forms of measurement include the need for
intubation and balloon distension under low constant pressure, which
may result in reflex relaxation of the stomach so that a true baseline
fasting volume cannot be estimated, and significant compliance of latex,
which necessitates correction each time the balloon is used since the
compliance may change with use as the latex is stretched by the water
within the balloon. The barostat measures a volume within a balloon
under constant pressure rather than true tone, volume, or tension in
absolute terms. These invasive tests are often unacceptable to patients
who are stressed and uncomfortable during these tests, which may last 3 h
or more. Given the practical limitations of balloon measurements of
gastric volume and accommodation, noninvasive volume-based methods
have been proposed to measure gastric capacity during fasting and
postprandially in the clinical setting and in research (Szarka and
Camilleri, 2009).

2. Single Photon Emission Computed Tomography

Single photon emission computed tomography (SPECT) imaging
has been extensively validated in vitro and in vivo for the measurement of
gastric volumes during fasting and postprandially. Validation includes
comparison to the gold standard, the barostat (De Schepper et al.,
2004).
After

intravenous

administration

of

1020

mCi

[99mTc]

pertechnetate, which is taken up by the parietal and mucin-secreting cells

of the gastric mucosa, tomographic images of the stomach are acquired
with the patient supine using a large field-of-view, dual-headed gamma
54

camera. From the transaxial images of the stomach, 3D images can be

reconstructed and total gastric volume can be measured during fasting
and during the first 30 min following a meal consisting of 300 ml Ensure
(Ross Products, Division of Abbott Laboratories, Columbus, OH; 316
kcal, 7.6 g fat, 50.6 g carbohydrate, and 11.4 g protein). Refinement of
the analysis programs has reduced analysis time from several hours to
less than 2 min on average per image of stomach in the fasting or
postprandial periods (Bouras et al., 2002).
SPECT demonstrates effects of disease on postmeal change in
gastric volume, a surrogate of gastric accommodation (Bredenoord et
al., 2003), and the effects of medications such as nitrates, erythromycin,
GLP-1, and octreotide (36, 80) in health and in diseases such as diabetes,
postfundoplication, and functional dyspepsia (Delgado-Aros et al.,
2003).
These effects of medications are consistent with those observed
with the barostat in the published literature. This noninvasive test does
not require intubation and measures the volume of the entire stomach, in
contrast to the barostat, which measures tone in part of the stomach
(Kuiken et al., 1999).
The effects of liquid and solid equicaloric meals on gastric volumes
have been described, and measurements of gastric volume with the same
caloric liquid meal an average of 9 mo apart show a coefficient of
variation of ~10% (De Schepper et al., 2004).
A new measurement is the simultaneous measurement of gastric
emptying and volume (Figure 12), first demonstrated by Parkmans group
(Simonian et al., 2004). This is of significant potential research interest
because it provides thorough assessment of the pathophysiology of the
stomach in disease. With the method described from Temple University,
55

gastric accommodation is calculated as the percent change in planar

(2D) gastric cross-sectional area by using a left anterior oblique planar
projection and the percentage change in total SPECT gastric voxel counts
(by 3D imaging) compared with baseline fasting volume using image
software. The procedure includes anterior and posterior images for
estimation of gastric emptying, followed by SPECT imaging with a
separate SPECT camera every 20 minutes. A Mayo Clinic study
confirmed the ability to measure the dynamics of gastric volume and
emptying functions in health using the same SPECT camera (Burton et
al., 2005).
Disadvantages of SPECT is that its equipment is not widely
available, and sophisticated software is needed to perform the 3D
reconstruction and volume rendering. Measurements can only be obtained
in the supine position, eliminating the influence of gravity, which is a
drawback shared with MRI. Gastric sensation cannot be assessed by
SPECT, unlike the barostat study. The main limitation for the evaluation
of accommodation by SPECT is the lack of effective treatment for
identified abnormalities (Szarka LA and Camilleri M, 2009).

56

Figure 12
Diagram showing the technique of measurement of gastric emptying and
volume by SPECT (Simonian et al., 2004).

3. Ultrasonography:
Imaging-based volume methods include analysis of surface
geometry of human stomach by real-time, 3D ultrasonography or, most
recently, by 3D reconstruction of images acquired by ordinary
ultrasonography assisted by magnetic scan-head tracking (Gilja et al.,
1995) and (Liao et al., 2004). In the most recent application of
ultrasonography, an outline of the total stomach volume is visualized after
ingestion of a liquid meal that serves as a contrast medium. 3D
ultrasonography has been applied in adolescents and compared with
simultaneously measured gastric volumes by SPECT; further validation
and standardization are necessary (Manini et al., 2009).

57

4. CT Volumetry
Evolution:
CT was first used as a technique for measuring the volume of
internal organs by Heymsfield et al. in 1979 using a method known as
the summation-of-area method. The validity was examined in 4
waterfilled balloons, 12 excised human cadaver organs (6 kidneys, 3
livers and 3 spleens) and 2 human cadaver organs (4 kidneys, 1 livers and
2 spleens) remained in situ. The CT-derived volume of an organ slice
could be calculated by multiplying area and width as described later in
the 'Technique' section. By comparing the CT-derived volume and actual
volume (by water displacement), they found the difference within 3-5%
and confirmed the accuracy of this method.
Henderson et al. (1981) later applied this technique to measure
hepatic and splenic volumes in cirrhosis. The liver and spleen volume
was measured in 11 normal subjects and 12 cirrhosis patients. The results
achieved

were

compared

with

that

obtained

with

ultrasound

determination of volume. Reproducibility of this CT technique in

measuring organ volumes was evaluated by repeating the process with
respect to the liver and spleen in living subjects. The coefficient of
variation for day-to-day variability was 6-10%; for inter-observer
variability, it was 4-8%. Hence they concluded that CT volumetry was a
clinically useful method of measuring organ volume with required
sensitivity.
Since Heymsfields and Hendersons original work, CT volumetry
has been used to measure tumour volumes in the liver (Decker et al.,
1978), pancreas (Chan et al., 1977) , and oesophagus (Liang et al.,
1996). Their results suggested that quantitative CT volumetry could be an
58

accurate technique for tumor assessment and response monitoring after

therapy. Liang et al. measured pre-operative tumor volume on spiral CT
sections in 10 patients who underwent oesophagectomy. CT derived
tumor volume was then correlated with actual tumor volume after
resection. To measure the cross-sectional area of the oesophageal tumor,
the inner and outer circumferences of the tumor were traced on the
console of scanner. A direct readout of the area between tracings was
obtained and multiplied by section thickness to obtain tumor volume per
slice. The sum volume of all involved sections gave the total tumor
volume. The volume of fresh operative specimen was measured by the
water displacement technique. A good correlation between CT derived
and actual tumor volumes (r=0.95) was obtained, thus validating CT
volumetry as an accurate measure of tumor volume assessment.
Technique:
Several authors have described their imaging protocols with
different multidetector CT systems for liver donor volumetry. The
contours of all liver sections were traced by means of a built-in cursor.
The manufacturers workstation with software automatically calculated
the number of pixels included within the traced contours on each section
and provided the cross-sectional area of the liver on a section-by-section
basis. The circumscribed areas were then automatically multiplied by the
CT section thickness, yielding an approximate volume for each liver
section, and the volumes of all sections were summed to give the selected
liver volume (Figure 13) (Zappa et al., 2009).

59

Figure 13
Basic principle of CT volumetry
Volume of single section = area x slice thickness
Overall volume = volumes in all relevant sections

By means of this method, the total volume of an object is

calculated with the aid of several cylindrical partial volumes. The partial
volumes result from segmentation of each complete object into adjoining
parallel sections of identical thickness. Each partial volume is calculated
as a product of its base and the constant section thickness selected or, in
the case of incomplete or overlapping techniques, of the section-tosection distance Leelaudomlipi et al. (2002) & Lemke et al. (2006).
The technique for gastric distention has been described for CT
examination of the stomach during Virtual Gastroscopy (VG). The
subject fasts for at least 8 hours and then receives 6 g of gas-producing
crystals with 10ml water orally to enable distention of the stomach before
the procedure is performed. The subject is then placed in the supine
position with his/her right side elevated at approximately 30. To ensure
60

adequate gastric distention, a scanogram is obtained. An additional 3 g of

gas-producing crystals is given to subjects determined to have insufficient
air distention. CT scan is obtained from the diaphragmatic domes to 2 cm
below the lower margin of the airdistended gastric body (Chen et al.,
2009).

61

PATIENTS AND METHODS

Patients:
This study had been conducted in Cairo University hospitals in the
period between August 2010 and April 2011 after approval from the
institutional review board and obtaining informed consent from all
patients including approval of protocol of treatment. Fifteen morbidly
obese patients were included and divided into 2 groups randomly. Group
1 underwent LSG. Group 2 underwent LGP. Ages of group 1 ranged
between 19 and 33 years. Ages of group 2 ranged between 23 and 46
years. BMI ranged between 45.3 and 53.6 Kg/m2 for the first group while
in the second group between 42.3 and 55.4 Kg /m2 (Table 1). Group 1
consisted of 4 males and 6 females, while group 2 cases were all females.
LGP (group 2)

LSG (group 1)

10

Number of cases

23

19

Lowest age

46

33

Highest age

31.6

26.7

Mean age

42.3

45.3

Lowest BMI

55.4

53.6

Highest BMI

49.46

49.83

Mean BMI

TABLE 1

62

Inclusion criteria:
All cases were chosen according to the following criteria:
BMI > 40 Kg/m2.
Age between 18 60 years.
No endocrinal causes for obesity.
Psychologically stable.
Sufficient non surgical trials to reduce weight.
Motivation & acceptance of surgical risks.
All patients were subjected to full clinical preoperative evaluation
as well as investigations.
Clinical evaluation aimed at assessment of degree of obesity,
preoperative evaluation and detection of different complications of
morbid obesity like hypertension, DM, sleep apnea, skeletal problems,
infertility, hernias, history of psychotherapyetc.

Investigations included :
Laboratory investigastions: CBC, FBS, renal functions, liver
functions, coagulation profile, lipid profile.
HORMONAL ASSAY to detect any endocrinal causes of obesity.
Pulmonary evaluation including X-ray chest & pulmonary
functions.
Cardiac assessment : ECG & Echocadiography if needed.

63

METHODS:
Surgical Technique:
Laparoscopic Sleeve Gastrectomy:
All procedures took place under general anaesthesia with the
patient lying in supine position. After induction of 15 mmHg
pneumoperitoneum, 5 trocars were inserted with sizes of 5, 10 and 12
mm. A window is dissected at the junction of the greater curvature and
the greater omentum, around 10 cm from the pylorus. Division of the
gastroepiploic, short gastric and posterior fundic vessels is done starting
at 4 cm proximal to the pyloric ring all the way till the angle of His using
the (ultracision Harmonic scalpel) (Harmonic; Ethicon Endosurgery,
Cincinnati, OH, USA) in all 10 cases. Once the dissection part is over, a
36 Fr bougie is introduced orally by the anaesthisiologist through the
oesophagus and inside the stomach. The surgeon then guides it along the
lesser curvature and into the pyloric channel and duodenal bulb.
Gastric transection begins 4 to 6 cm proximal to the pylorus. A 60mm, green or gold cartilage, is placed across the antrum through the right
midepigastric port and fired. The second stapler is placed approximately
1 to 2 cm from the border of the lesser curvature in the direction of the
GE junction. The bougie must be held in position during this part of the
procedure until completion of the stomach transection to avoid stapling
across a displaced bougie.
Sequential firings of the stapler along the border of the bougie on
the lesser curvature completes the gastric transection at the left crus. After
completing the transection, the entire staple line is inspected carefully to
make sure that the staples are well formed especially at the antrum where
64

the stomach is thickest. The transected stomach then is removed through

one of the 10-mm port sites. After completion of the gastric transection
the integrity of the staple line is tested by Methylene blue with the
pylorus compressed by a surgical grasper. Methylene blue is injected (via
the bougie) into the stomach and the staple line is inspected carefully to
exclude macroscopic leaks of the suture line. The dye is then removed
from the stomach, as is the bougie. All trocar sites are closed with 0
Vicryl (Ethicon) using a suture passer to prevent abdominal wall hernias
(Figures 14 18).

Figure 14
Dissection of the greature curvature

65

Figure 15
Dissection of gastro-splenic ligament

Figure 16
Last step in greater curvature dissection

66

Figure 17
Firing the first stapler

Figure 18
Firing the last stapler

67

Laparoscopic Gastric Plication:

The first part of surgical technique in LGP is exactly similar to that
of LSG till devascularization of the entire greature curvature of the
stomach (except for the distal 4 cm) is achieved but with few mms far
from the edge of the stomach to avoid thermal injury to the gastric wall
by the harmonic . The next step was to initiate gastric plication by
imbricating the greater curvature over a 36-Fr bougie and applying a first
row of extra-mucosal continuous stitches of 2-0 Ethibond sutures. This
row guided two subsequent rows created with extra-mucosal running
suture lines of 2-0 Ethibond. The reduction resulted in a stomach
shaped like a large sleeve gastrectomy (Figure 19).

Figure 19

68

Follow-up of patients:
In the postoperative period, all patients were given 3rd generation
cephalosporins, anticoagulants, opioids, proton pump inhibitors and
antiemetics. Gastrographin meal was done to all patients in day 0. In day
one, all patients started oral fluids (if tolerated) after confirming that there
is no leakage in the study. All patients continued on oral fluids for one
month, followed by soft diet for another month and lastly on semisolids
for one more month. The drain was removed before discharging the
patients. All patients were discharged on day 2 after meeting the
discharge criteria of no bleeding, no leakage and no other complications.
All patients were followed up for one month on an outpatient basis.
CT volumetry were done to all patients at the end of the first
postoperative month.

CT Volumetry:
Patients Preparation:
Plain abdominal CT was performed on a Multislice CT 64-section
detector scanner (GE) (General Electric Medical Systems, Milwaukee,
WI, USA). All patients fasted for at least 8 hours before performing the
study. Before the CT examination, two packs of effervescent granules
were added to 10 ml of water and administered orally to each patient.
Patients were placed on the scanning table in the supine position. A scout
projection is then obtained showing the stomach fully distended by gas. If
the stomach is inadequately distended, one more pack is administered
orally to ensure adequate distension. A delay of 10 15 seconds was
needed to ensure complete distention of the stomach.

69

CT protocol:
Images were obtained from a level 12 cm below the dome of the
diaphragm to the lower pole of the right kidney during a single breath
hold. The helical CT data acquisition parameters were 120 kVp, 600 700 mA, 1.25 mm collimation, 5 mm reconstruction interval and rotation
time of 0.7 seconds. To complete imaging within the breath-hold period,
all image acquisition was completed within 30 to 40 seconds.
The 1.25-mm transverse CT sections were reconstructed at 0.5-mm
intervals, performed at a commercially available workstation (Advantage
Windows 3.1; GE Medical Systems). The contours of all stomach
sections were traced by means of a built-in cursor. During 3D
reconstruction for volumetry in LSG patients, the first section starts from
the most proximal radiodense staple till the pyloric ring. In case of LGP,
it starts roughly at the gastro-esophageal junction. The manufacturers
workstation with a specific software automatically calculated the number
of pixels included within the traced contours on each section and
provided the cross-sectional area of the stomach on a section-by-section
basis. The circumscribed areas were then automatically multiplied by the
CT section thickness, yielding an approximate volume for each stomach
section, and the volumes of all sections were summed to give the selected
stomach volume.
All data were statistically analyzed.

70

DISCUSSION

In recent years, the minimally invasive approach has become the

preferred technique for bariatric surgery. All bariatric procedures are now
routinely performed laparoscopically. Explanations for this trend include
several advantages related to less postoperative discomfort and reduced
surgical risk for obese patients (Silecchia et al., 2008). Beginning with
gastric banding and vertical banded gastroplasty, followed by gastric
bypass, gastric sleeve, duodenal switch, biliopancreatic diversion, the
laparoscopic approach has gradually replaced the corresponding
traditional open operations (Schauer et al., 2001).
With the exception of bariatric surgery, severely obese individuals
have few effective weight control options. Bariatric surgery produces
large weight losses which are shown to be maintained for 10 years and
longer, although some patients do not achieve adequate weight loss and
others experience considerable weight regain. These outcomes are
increasingly attributed to variability in patient compliance with pre- and
post-operative behavioral recommendations, particularly those related to
eating and activity habits (Bond et al., 2009).
In a series of 1120 patients that underwent LAGB in 2002,
OBrien and Dixon reported an early peri-operative complication rate of
1.5% and late complication rate of 14%. Complication rates reported by
others (Favretti et al., 2002) and (Angrisani et al., 2001) ranged from
3.9 to 11.3%. Re-operation and band failure are still the most challenging
problems of this surgery. The meta-analysis conducted by Maggard et al.
has shown that around 7.7% of patients require re-operation for band
removal, usually due to intolerance, infection, band slippage, and band
71

erosion. Moreover, the degree of weight reduction attained was relatively

minimal compared to other bariatric procedures (sleeve gastrectomy and
gastric bypass). The procedure is less effective for patients with poor
dietary compliance and those with high BMIs.23 In contrast to patients
with lower BMIs (<60 kg/m2), super-obese patients require a longer
period of follow-up to accomplish a similar percentage of EBW loss
(Maggard et al., 2005).
RYGB is certainly one of the more technically challenging
laparoscopic procedures performed today. Both the size of the obese
patient and the complexity of these reconstructive procedures create the
major technical barriers. Surgeons must perform such complex tasks as
gastric pouch creation, Roux limb creation, two anastomoses, and closure
of mesentericdefects (to avoid internal hernia formation). Advanced skills
such as laparoscopic suturing, stapling, and dissection techniques must be
mastered. Patient factors such as massive obesity (BMI > 60), severe
hepatomegaly, prior abdominal surgery, and reoperative bariatric surgery
may increase the degree of difficulty by several magnitudes. Early
perioperative complications for RYGB include
postoperative anastomotic leak, bowel obstruction, and
hemorrhage (Bult et al., 2008). Late surgical
complications for RYGB include anastomotic stricture,
bowel obstruction, and incisional hernia (Papamrgaritis
et al., 2010).
The weight loss associated with a sleeve gastrectomy alone can be
substantial. In addition, several small series have noted a significant
decrease in associated comorbidities after a sleeve gastrectomy. Several
studies have been published that have suggested that a laparoscopic

72

sleeve gastrectomy can be performed as a definitive weight loss

procedure (Frezza, 2007).
Interesting data were presented at the First International Consensus
Summit for Sleeve Gastrectomy in October 2007. According to this
summit, there were 10 centers in the USA that had achieved a 5-year
follow-up. Only one death was reported in the first 260 patients. Sleeve
gastrectomy according to the data presented at the summit represents 2 %
of the bariatric operations in the USA. This took place despite the fact
that the surgery had no specific insurance code (Akkary et al., 2008).
Importantly, rates of complications have varied significantly
between authors (Frezza et al., 2009) with gastric leak being the
complication of greatest concern. Anecdotally it would seem that when
leaks occur in sleeve gastrectomy they are usually proximal and result in
significant difficulties. Often multiple operations are required, with early
intervention being the key to resolution. Prolonged fistulae are common.
Collections are practically inevitable. Leaks appear more difficult to
resolve than leaks from gastric bypass surgery, presumably because of the
high gastric pressures and acid and bile content in the gastric sleeve
remnant. Serra C et al. (2007) have suggested that gastric stenting may
have a role in leak management. In addition sleeve gastrectomy is an
irreversible procedure.
LGP is notably similar to a LSG in that it generates a gastric tube
by means of eliminating the greater curvature but does so without gastric
resection. It is likely that LGP greatly reduces the possibility for gastric
leaks. Talebpour and Amoli report one case of a gastric leak associated
with a more aggressive version of LGP, which the authors attributed to
excessive vomiting in the early postoperative period (Talebpour and
Amoli, 2007). In two separate papers, Fusco et al. report efficacy in
73

gastric plication procedures, as measured by changes in the weight

progression of rats (Fusco et al., 2006) and (Fusco et al., 2007). In one
paper, Fusco et al. report an increased effect from plication of the greater
curvature when compared to plication of the anterior surface.
Calibration during sleeve gastrectomy is guaranteed through the
use of different bougie sizes (32- to 50-Fr), however this is not available
in gastric plication since the residual volume will depend on the tightness
of sutures, the site of starting and ending sutures in fundic and pyloric
regions in addition to the size of the bougie used in calibration.
Kim et al. (2003) conducted a research on CT gastrography in 51
patients with different gastric diseases, and used the same volumerendering technique reported in our study. However, to date,
measurement of residual gastric volume in post-bariatric patients has not
been reported in literature.
With the development of new multi-detector computed
tomographic (CT) techniques and software, radiologists can now play an
important role in predicting the outcome of two of the most recent
restrictive bariatric procedures. Although other factors should always be
taken in consideration, as the neurohormonal effect of LSG in reduction
of ghrelin levels in the body, residual gastric volume remains the most
important in all factors concerning restriction of stomach size, and has
always been the main concern of surgeons in the bariatric surgery
community.
In our cases, though small number, the average residual gastric
volume in sleeve gastrectomy cases was 96.6 cm3, while in cases of
gastric plication was 357.1 cm3 which could point out to the fact that
concerning residual volume of the stomach, LSG provides better results
regarding short-term changes of the gastric volume. However, a period of
74

one month is not enough to assess the degree of gastric dilatation, if any,
that could occur after both procedures. More importantly, more time is
needed to investigate the amount of weight loss that both procedures
provide, which is the main parameter when it comes to assessing any
bariatric operation.
We would also like to shed light on the technique through which
the residual gastric volume has been assessed, CT volumetry, which has
proven its efficacy in evaluation of the volume of other organs, such as
the liver, but has not been widely used in assessing the stomach. More
research is needed in order to prove its accuracy with this particular
organ, which, if done, should provide a true evolution in the prediction of
the outcome of these two bariatric procedures and other restrictive
procedures as well.

75

CONCLUSION AND SUMMARY

Morbid obesity is an epidemic disease, and its prevalence is
predicted to rise in the future. Nowadays, bariatric surgery is the only
effective treatment for severe obesity. Several restrictive procedures have
been implied by surgeons all over the world, where, recently,
laparoscopic sleeve gastrectomy has been gaining popularity over the
other procedures. Another restrictive procedure, laparoscopic gastric
plication, is new & relatively unknown among the obesity surgeons
community.
In this study, 15 morbidly obese patients underwent bariatric
restrictive procedures, & were divided into 2 groups. Group 1 underwent
Laparoscopic Sleeve Gastrectomy (10 patients). Group 2 underwent
Laparoscopic Gastric Plication (5 patients). CT volumetry, a recent and
non-invasive method used in the measurement of the volume of internal
organs, was used to assess the residual volume of the stomach 1 month
after the procedure for each group.
In group 1 patients, with a mean BMI of 49.65, the average
residual volume of the stomach was 96.6 cm 3. In group 2 patients, with a
mean BMI of 49.83, the average residual volume of the stomach was
357.1 cm3. Complications that occurred in group 1 were: vomiting (3
cases), fever (2 cases), and lung atelectasis (1 case). Complications that
occurred in group 2 were: vomiting in all cases, port site wound infection
20 %.
Concerning short term volumetric changes, LSG provides better
results regarding the residual volume of the stomach. However, long term
76

evaluation of the post-operative changes in the gastric volume needs to be

assessed to provide better judgment on both bariatric procedures.

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