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Case study

First experience of lap adjustable banded LSG

In a case study from Russia, investigators report on their first experience of laparoscopic adjustable banded sleeve gastrectomy with one year follow-up to treat a super-super obese patient.

Authors: Khatkov I.E.1,2, Askerkhanov R.G.1,2, Feidorov I.J.1, Bodunova N.A.2

  1. Moscow Clinical and Scientific Centre. Moscow. Russia.
  2. Moscow State University of Medicine and Dentistry named after A.I. Evdokimov, chair of Faculty Surgery.

Igor E Khatov

Surgical approach is the most effective treatment for patients with morbid obesity [1]. It’s generally known, that surgical treatment of super-super obesity (BMI>60 kg/m2) and high-risk patients with comorbidities, is responsible for an increased risk of postoperative morbidity and mortality after bariatric surgery [2]. Moreover, there are some specific difficulties in laparoscopic surgery for extremely obese patients such a neediness for increased pressure CO2 in abdomen, long instruments, increased resistance of abdominal wall, sometimes additional ports or modification of a ports placement. Sleeve gastrectomy is a recently used surgical technique, with an acceptable rate of postoperative complications[3]. It was describe as a first step before a gastric bypass or biliopancreatic diversion with duodenal switch. The advantages of this procedure include lack of an intestinal bypass, thus avoiding gastrointestinal anastomoses, metabolic derangements, and internal hernias, shorter operating times, and no implantation of a foreign body [4]. There are not rare cases when laparoscopic sleeve gastrectomy was described as a revision bariatric procedure for failed gastric banding [5-7]. But there are some publications about banded sleeve gastrectomy in case extremely obese patients for gastric dilatation prevent, that may limit weight loss [8-10]. This case report presets our first experience of laparoscopic adjustable banded sleeve gastrectomy with one year follow-up in case of super-super obesity patient.

Patient N., 38-years old female, the biggest Russian woman, weight 267 kg. and BMI 84.3 kg/m2 was admitted to our clinic for assessment current status about bariatric procedure. From her medical history, in her 20-ties she has a 70-74 kg weight with 178 cm height and works as a confectioner. Then step by step she began to notice an increase in weight about 1 or 2 kg per every month. In her 30 she has a 120 kg (BMI 37,87 kg/m2), then in 34 years, during the pregnancy her weight increasing 70 kg more and was 240 kg. After the childbearing (by the Caesarian) by the diet 50kg weight loss, but after dietotherapy was stopping her weight was regain till the admission to hospital.

Related diseases: purulent meningitis and then suicide attempt by the medicines, stabbing, two cranial traumas, rheumatism with heart disease, high grade myopia, varicose without any trophic changes, anxious depression. During the preoperative instrumental examination was performed: upper endoscopy – duodenal reflux, ultrasound (thyroid, abdominal cavity and gynecology) with no significantly changes, echocardiography – middle pulmonary hypertension; Doppler ultrasound of feet vessels was not informative, 24 hours electrocardiography with middle rate of ventricular ectopic beats (186) and low rate of supraventricular ectopic beats (16), 24 hours monitoring of blood pressure with no pathology changes. In her laboratories tests there was iron deficiency (without clinical signs) was no signs of hyperglycemia (5,4 – 5,9 mmol/l), Hgb – 11,5 g/dL, Protein total – 66,9 g/l, Cholesterol (serum) – 3.88 mmol/l, HDL – 0.93 mmol/l, LDL – 2.28 mmol/l, K+-4.03 mmol/l, Na+- 139.6 mmol/l, Ca++- 2.27 mmol/l, Fe++ - 7,7 mkmoll/l. In order of preparation for surgery was appoint course of antidepressants (Zoloft 100 mg 1 time per day), light diet, no pre-surgery CPAP therapy or sleep studies, no cardiorespiratory referral.

In April 2013 patient N. was operated. The patient was placed in the supine position with a spread her legs, and then Trendelenberg after first port placed. Four ports technique were used (Figure 1): 10 mm – camera port., 12 mm. – main surgeon port, 5 mm – surgeon assistant port, 5 mm assistant port, and epigastric 5 mm port for Nathanson liver retractor to retract the left lateral liver segment.

Picture 1: Surgical team and ports placement

Gastric mobilization by the Harmonic scalpel (Johnson and Johnson, USA), using it, the window into omental bursa was made about 5 cm proximal to the pylorus. Big gastric curvature was mobilized till the left diaphragmatic crus and esophagus visualization, short gastric vessels was carefully seal and divided. Sleeve was created on the 33 Fr bogie by the Endo GIA stapler (Covidien, Ireland) using 45 mm green cassettes 2 pieces, 60 mm blue cassettes 4 pieces. In order to prevent staple line leaks, staple line was oversewed by the vicryl 3-0 run suture. Then the adjustable gastric banding system (Medsil, Russia) was placed on the gastric sleeve 3 cm lower esophago-gastric junction without gasro-gastric sutures. Thereby gastric band ring was fixed only in lesser omentum. At the end of surgery abdomen cavity was drained in splenic sinus area and banding system port was placed on the aponeurosis of the external oblique abdominal muscles by the anterior axillary line. The patient has a favorable for early and later postoperative period, she starts to drink at 2 day after surgery and then during 3 weeks has a soft diet. At the 3-rd day after surgery patient was transferred at general therapy unit and then discharged at 6-th day after surgical procedure.

The patient N was admitted to our clinic after 3 and 6 months after surgery for alimentary, laboratory and psychological status assessment and instrumental examination. There are no pathological changes in laboratory and instrumental (X-ray barium scan, upper endoscopy and abdomen ultrasound scan) tests and good laboratory results: Hgb – 14,5 g/dL, Protein total – 71,9 g/l, Glucose 5.37 – 7.09 mmol/l, Cholesterol (serum) – 4.28 mmol/l, HDL – 1.34 mmol/l, LDL – 2.35 mmol/l, K+-3.75 mmol/l, Na+- 139,2 mmol/l, Ca++- 2.45 mmol/l, Fe++ - 8,2 mkmoll/l (hide iron deficiency without clinical signs). Weight loss year after bariatric procedure about 100 kg, BMI-52,7 kg/m2. Stable weight loss during the whole year without band adjustments. Favorable psychological status with no depression conditions after psychotherapy course.

This case presented laparoscopic adjustable banded sleeve gastrectomy as safe and effective bariatric procedure for extremely obese patient with high risks for surgery.


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