Laparoscopic Sleeve Gastrectomy for the Surgical Treatment of Obesity: Is It an Easy Procedure?

Laparoscopic sleeve gastrectomy (LSG) is currently the most performed bariatric procedure in the world. The 4th International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) Global registry report (2014-18) estimates 87,015 procedures, equal to 45.9% of all bariatric procedures. Initially performed as the first step of the duodenals witch (biliopancreatic diversion with duodenal switch (BPD-DS)), a very complex malabsorptive procedure invented by a Canadian Surgeon P. Marceau as an evolution of the BPD, invented by N. Scopinaro, an Italian surgeon, LSG established itself in the early 2000s as a stand alone procedure, especially following the observations of Michael Gagner, pioneer of bariatric surgery. Over the years LSG has grown rapidly. The reasons for this popularity are the relative technical simplicity compared to other procedures, efficacy, good quality. For these reasons there has been a real explosion of bariatric surgery: many surgeons, driven by the relative simplicity of the procedure (longitudinal gastrectomy on the guide of a probe), begun to propose this procedure. So is LSG really an effective simple procedure that is good for all patients? Absolutely not. Performing a longitudinal gastrectomy can be simple; performing a good LSG is not.

Ursodeoxycholic acid for the prevention of gallstone disease after bariatric surgery

Background: The development of gallstone disease (GSD) after bariatric surgery is a significant problem. The prophylactic effect of ursodeoxycholic acid (UDCA) preparations on the occurrence of cholelithiasis after gastric bypass and longitudinal gastrectomy has been studied. Aims: The aim of the study was to evaluate the effectiveness of ursodeoxycholic acid preparations in the prevention of cholelithiasis in patients after bariatric surgery. Methods: The results of a year-long follow-up for 128 patients after bariatric surgery were analyzed. In 68 patients, the prophylaxis of the gallstone disease development was not performed. 60 patients took a daily 500 mg dose of UDCA orally. Results: Cholelithiasis had developed in 17 (25%) patients who did not undergo the prophylaxis of cholelithiasis. Of these, 10 (14.7%) underwent cholecystectomy. Among those patients who took UDCA drugs, stones in the gallbladder were found in 7 (11.6%), and only one patient (1.7%) required a surgical treatment. Conclusion: UDCA administration during the first year after bariatric surgery in the amount of 500 mg per day significantly reduces the likelihood of the de novo cholelithiasis development. The medical prophylaxis of gallstone disease should be included in the standards of bariatric patients' management.

Longitudinal Gastrectomy for Nonbariatric Indications

Background. Sleeve gastrectomy is the most commonly performed bariatric procedure. Laparoscopic longitudinal gastrectomy (LLG) may be indicated for other indications. Patients and Methods. Two men and two women aged 67, 72, 77, and 80 years underwent LLG for nonbariatric indications with two having normal weight, one being cachectic, and one severely obese. Results. LLG was discussed with patients prior to surgery, but decision for LLG was made during surgery after contemplating other surgical options. A wide sleeve over a 42 French bougie was created with the staple line being oversewn with running 3–0 silk. Indications included a bleeding Dieulafoy lesion that failed endoscopic clipping, fundus gland polyposis found during paraesophageal hernia repair, fundus nodules suspected to be leiomyosarcoma metastases revealing splenosis on final pathology, and significant gastric dilatation associated with organoaxial gastric volvulus. Three patients had an uneventful recovery; the severely obese patient temporarily lost weight but died after two years from a stroke. The last patient developed dysphagia due to an alpha-loop in the sleeve, which was managed by endoscopic stenting. The device subsequently migrated and was laparoscopically removed, with a side-side gastrogastrostomy performed to straighten the alpha-loop. The patient tolerated food better and with overnight PEG tube feeds gained weight but continued heavy smoking. He died after one year from COPD exacerbation. Conclusion. LLG seems to be an appropriate intervention for various gastric pathologies. Training of residents and fellows in the minimally invasive surgical steps of LLG is encouraged.

Case of insulinoma detected in a patient after bariatric operation for morbid obesity

The prevalence of insulinomas is 13 cases per million population per year of which 414% tumor is malignant. Weight gain is one of the symptoms of the disease, often resulting in morbid obesity with indications for surgical treatment. The presented clinical case demonstrates the successful treatment of malignant insulinoma with the manifestation of hypoglycemic syndrome after carrying out biliopancreatic bypass with longitudinal gastrectomy for morbid obesity.

General anesthesia without opioids in surgery for morbid obesity. What for and how?

The paper presents the experience of applying the technique of general opioid-free anesthesia and postoperative analgesia in bariatric laparoscopic surgery that was developed by Belgian specialists. Thirty patients with body mass index of 48±5,3 kg/M2 were operated using this technique. All of the patients underwent laparoscopic longitudinal gastrectomy. Anesthesia was induced using propofol 230±25 mg and maintained by sevoflurane in concentration of 0,7-0,9 MAC combined with 50%-65% nitrous oxide as well as multimodal analgesic infusion (0,9% NaCl 1000,0 + lidocain 600 mg + ketamine 50 mg + dexmedetomidine 100μg + MgSO4 25%-5 g) with administration rate of 1,0-1,3 ml/кгLBM/hour, where LBM - lean body mass equaled to ideal body mass (IBM). Miorelaxation was achieved using esmeron in dose of 0,6 mg/kg IBM. Reversal of neuromuscular block was performed in 10 patients using sugammadex. The infusion of analgesic solution was continued for 8-10 hours after the operation. All the patients got up and walked within a ward 4-5 hours after the surgery. The activation accompanied with increasing of pain in the operation zone and tangible discomfort in 20 patients who required the enhance of analgesia using opioids. The proposed technique facilitates the early postoperative activation that is very important for the patients suffered from morbid obesity.

Bariatric surgery in Russia in 2011-2013

Within three years (2011 - 2013), we collected data on the operations carried out by sending a questionnaire to members of the Russian Society of Bariatric Surgeons. In the questionnaire were asked to fill in a table on the total number of operations, their structure, subject to the applicable access and report on fatal cases indicating the cause of death.The number of executed operations (excluding installation gastric balloon) increased from 989 to 1525.In 2012, steel longitudinal gastrectomy performed more often than banding. The share gastroshuntirovany continues to decline throughout the period.In 2013, against the backdrop of a significant increase in the number of bariatric interventions deaths were recorded.