Introduction:
Hess initially conducted sleeve gastrectomy as part of biliopancreatic diversion with the duodenal switch (BPD-DS) operation, which derived from Scopinaro's BPD and DeMeester's duodenal switch (DS) procedures. As laparoscopic surgery advanced during the 1990s, Gagner conducted the first laparoscopic sleeve gastrectomy as part of BPD-DS in 1999. Sleeve gastrectomy gradually gained favor as a less challenging treatment in the early twenty-first century. Before a definitive procedure with gastric bypass or biliopancreatic diversion surgeries, it was first employed as a first-step therapy for super-obese patients (body mass index greater than 60 kg/m2). Presently laparoscopic sleeve gastrectomy (LSG) is regarded as a primary laparoscopic bariatric treatment, considering its numerous benefits.
What Are the Underlying Mechanisms of Action?
The LSG procedure is a restricted bariatric procedure. Weight reduction is accomplished by greatly lowering stomach volume, which leads to decreased food intake. Furthermore, postoperative hormonal alterations in bariatric patients lead to decreased appetite, reduced food intake, and long-term weight loss. Ghrelin is a hormone generated largely by the oxyntic cells of the fundus of the stomach while fasting. It stimulates hunger by enhancing the expression of the orexigenic hypothalamic neuropeptide Y (NPY). After eliminating the gastric fundus, sleeve gastrectomy patients had significantly lower levels of ghrelin and lowered appetite. Peptide YY (PYY), a hormone formed postprandially from the stomach, blocks NPY release and has an anorectic effect (lack of appetite). Following a sleeve gastrectomy, PYY is significantly elevated, resulting in increased satiety and decreased food consumption. In response to indigestion of food, enteroendocrine L-cells in the gut release glucagon-like peptide-1 (GLP-1).
Is There Weight Loss After LSG?
LSG has a significant benefit in that, although being a simple, fast, and safe bariatric surgery, it is also a successful surgical procedure, allowing patients substantial excess weight loss.
Nutrient Deficiencies:
- Obese patients are often malnourished, owing to a diet rich in fats and carbohydrates but lacking quality protein, dairy, and vegetables. Most nutritional and micronutrient deficiencies remain postoperatively in individuals after bariatric surgery, necessitating multivitamin therapy.
- On the other hand, nutritional inadequacies vary considerably between bariatric procedures, with LSG having little influence on nutrient status. Like other bariatric operations, the most usually reported nutritional deficiencies, such as iron, folate, and thiamine, remain postoperatively but are readily remedied with regular multivitamin treatment.
- When an iron supplement is taken postoperatively, the risk of anemia following LSG is decreased compared to other types of surgeries. Postoperative hypovitaminosis D, vitamin B12 insufficiency, on the other hand, is uncommon following LSG due to adipose tissue loss and sufficient supplementation.
- In contrast to other malabsorptive bariatric procedures that bypass the duodenum, the absorption of vitamin B12 is not disrupted in LSG.
Improvement in Metabolic Changes (Diabetes):
LSG has a favorable effect on diabetes and excess weight reduction. According to several studies, type 2 diabetes mellitus (T2DM) disappears in many individuals with LSG. Type 2 diabetes mellitus control is achieved following LSG, like other bariatric procedures, with speedy excessive weight loss. However, early after LSG, glycemic control without diabetes medication, hemoglobin A1c normalization, and improvement or even cure of T2DM was observed.
Improvement in Systematic Diseases (Comorbidities):
Besides diabetes mellitus, LSG improves and even cures several conditions. Several studies have found that LSG improves or cures hypertension, dyslipidemia, obstructive sleep apnea, and degenerative joint disease. Obstructive sleep apnea, frequent in morbidly obese people, can be treated in 80 percent of cases with surgical surgery.
Improvement in Quality of Life (QOL):
Laparoscopic sleeve gastrectomy significantly improves the quality of life (QOL) and psychosocial functioning. LSG is a pill and food-friendly bariatric procedure. Pills and medications like aspirin and NSAIDS are often well tolerated. Furthermore, dietary tolerance is excellent, particularly over time. Most patients report great satisfaction following surgery, and a large percentage of them gradually convert their eating habits to a better diet. Physical activity, sexual life, and self-esteem are also improved postoperatively due to speedy recuperation and appropriate weight reduction.
How Is Laparoscopic Sleeve Gastrectomy Performed?
The recognition of the Crow's foot, pylorus, and antrum is the initial stage in LSG. Following that, a window is created lateral to the antrum in the greater omentum. Most specialists consider mobilizing the fundus before transection and resecting the short gastric arteries before stomach division. This will aid in forming a tiny gastric pouch and identify any hiatal hernias. If there is a hiatal hernia, it should be corrected at the same surgery by posterior crural approximation. The distance from the pylorus from which the gastric division should begin is one of the most debatable areas in LSG. The objective of the surgeon is to prevent a leak by performing a restricted bariatric procedure with better stomach emptying and lower intraluminal pressure. The group of experts 2012 concluded that the transection should start 2 to 6 cm from the pylorus.
What Are the Indications of Laparoscopic Sleeve Gastrectomy?
- Laparoscopic sleeve gastrectomy should be regarded as a main bariatric operation or the first part of a 2-step strategy for the treatment of morbidly obese individuals.
- Later, LSG was utilized to treat very obese or high-risk patients before undergoing a projected second-stage bariatric treatment within two years.
- Laparoscopic sleeve gastrectomy has been demonstrated to be both safe and successful in the treatment of obese IBD patients.
- For high-risk surgical patients, LSG appears to be a realistic and safe treatment. It can be utilized as a safe initial surgical operation in high-risk patients who need to have a second non-bariatric procedure such as knee replacement, nephrectomy, or spine surgery to achieve fast weight loss.
- Laparoscopic sleeve gastrectomy can be successfully accomplished in cirrhotic patients with little risk of postoperative complications, enhancing their metabolic syndrome and lowering hepatic steatosis.
- Other indications include situations in which the small bowel is inaccessible because of adhesions from previous procedures and patients who require repeat endoscopy of the duodenum.
What Are the Contraindications of Laparoscopic Sleeve Gastrectomy?
- Barrett's esophagus is the sole absolute contraindication to performing LSG. The development from erosive reflux condition to Barrett's esophagus, as well as gastric and esophageal cancer, is well known.
- However, the existence of gastroesophageal reflux disease (GERD) before surgery is merely a relative contraindication, owing to the fact that reflux symptoms may increase following LSG.
What Are the Complications of Laparoscopic Sleeve Gastrectomy?
Early complications of large laparoscopic surgical operations include bleeding, gastric leak, blockage, formation of abscess, wound infections, and all the other post-operative side effects of major laparoscopic surgeries. Late complications of LSG include fistula formation, gastroesophageal reflux disease, stenosis, neofundus, spiral sleeve and intrathoracic sleeve migration of the sleeve, failure to lose weight, and nutritional deficiency.
Conclusion:
It is a simple and straightforward procedure that does not need anastomosis (surgical connections between two structures) and preserves the continuation of the gastrointestinal system. The complications, including serious ones, are reasonable, and the death rate is remarkably low. Laparoscopic sleeve gastrectomy is helpful for long-term excess weight reduction and comorbidity resolution, with minimal dietary deficits and acceptable patient tolerance. Finally, laparoscopic sleeve gastrectomy deserves a position among the bariatric surgeries undertaken.
