Published online: May 8, 2014

Dig Surg 2014;31:40–47 DOI: 10.1159/000354320

State of the Art: Sleeve Gastrectomy Bettina Wölnerhanssen a Ralph Peterli b Department of Biomedicine, University Hospital, and b Department of Surgery, St. Claraspital, Basel, Switzerland

Key Words Biliopancreatic diversion · Laparoscopic sleeve gastrectomy · Glycemic metabolism

Abstract In the biliopancreatic diversion (BPD) type duodenal switch, sleeve gastrectomy was applied as the restrictive part instead of a horizontal gastrectomy in the original Scopinaro type BPD. Laparoscopic sleeve gastrectomy (LSG) was used as a first step in a staged concept for high-risk patients undergoing bariatric surgery. However, it is now being increasingly favored as a stand-alone procedure. This article discusses the history, surgical technique, early results, metabolic effects, mid- to long-term results regarding weight loss, improvement of comorbidities and quality of life, management of complications and indications. LSG is a safe and effective bariatric procedure with satisfying weight loss results and effects on comorbidities. Further data are required to assess long-term effectiveness and safety of LSG. In patients with very high initial BMI, LSG can be used in a staged concept. Other indications are: in cases with dense adhesions of the small bowel, patients with inflammatory bowel disease and patients where repeated endoscopy of the duodenum is necessary. © 2014 S. Karger AG, Basel

© 2014 S. Karger AG, Basel 0253–4886/14/0311–0040$39.50/0 E-Mail [email protected] www.karger.com/dsu

Introduction

Laparoscopic sleeve gastrectomy (LSG) as a standalone bariatric procedure is becoming increasingly popular throughout the world. Between 2003, 2008 and 2011, it increased from 0 to 5.3 to 27.9% of all bariatric procedures worldwide, even more so in Europe [1]. Initially, sleeve gastrectomy was the restrictive part of biliopancreatic diversion duodenal switch (BPD-DS). In the early 1990s, Hess and Hess [2] and Marceau et al. [3] performed a longitudinal gastric resection as a variation of the original Scopinaro type BPD with a horizontal gastrectomy [4], mainly to decrease the rate of anastomotic ulcers by preserving the pylorus and reduce the number of revisions. Paiva et al. [5] performed the first LSG in 2000 in the context of the first laparoscopic BPD-DS (LBPD-DS). High early morbidity and mortality of LBPD-DS in patients with high BMI (>60) led to a staged concept with primary LSG to induce initial weight loss, followed either by laparoscopic Roux-en-Y gastric bypass (LRYGB) or LBPD-DS in case of insufficient weight loss [6]. However, a number of patients did not go through the second-stage operation due to sufficient weight loss and high patient satisfaction following LSG. Contrary to the opinion that the LSG is a purely restrictive procedure, it could be shown that LSG has strong metabolic effects by reducing orexigenic ghrelin levels, mainly produced in the gastric fundus but possibly also PD Dr. Ralph Peterli Department of Surgery St. Claraspital CH–4016 Basel (Switzerland) E-Mail ralph.peterli @ claraspital.ch

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a

Mechanisms

Weight loss and metabolic effects such as amelioration of glucose homeostasis after LSG is achieved by three main mechanisms: reduction in stomach volume capacity and thus reduction in food intake, and mechanical and hormonal changes. Reduction in Stomach Volume Doubtless, the reduction in stomach capacity is important for weight loss. The remaining reservoir is minimal and the sleeve has more or less the function of a prolonged esophagus. Whether long-term outcome depends on sleeve size is still a matter of debate: Some studies conclude that more restrictive LSGs (bougie size 12,000 LSG procedures in total published by Rosenthal [28]. It may be much easier to perform compared to LRYGB, but there are a number of pitfalls that have to be taken into account [29]. The operation can be performed in a French position with four trocars and a liver retraction device. Single-port and natural-orifice techniques have also been described, but their benefit in the morbidly obese patient have yet to be demonstrated. It is important to have a bougie inserted to calibrate the gastric remnant, most often 32–36 Fr in size. Whether larger bougies may lead to less weight loss in the long term is still a matter of debate (see above). The use of more narrow bougies creating a tighter sleeve might in fact increase the risk of leakage and dysphagia [30, 31], although in Rawlins series, this was not the case [10]. In order to make a perfect sleeve, the dorsal wall of the stomach has to be dissected completely; adhesions to the pancreatic capsule must be fully freed. If not, there is a risk of leaving parts of the stomach inside with consecutive dilatation and weight regain. For that reason, it seems better to first fully dissect the greater curvature, starting in the middle of the corpus instead of performing the sleeve through a small window of the greater curvature. The dissection has to be completed until the angle of His is freed; all short gastric vessels have to be taken down and the left phrenic pillar needs to be fully visualized. If there is suspicion of a hiatal hernia, the hiatus has to be freed and the 42

Dig Surg 2014;31:40–47 DOI: 10.1159/000354320

right pillar dissected also to allow a closure of the hiatus (over the inserted bougie) for prevention of reflux in the future. In large hiatal hernias, mesh reinforcement can be an option. The dissection of the greater curvature is continued towards the pylorus, often a little further down than the beginning of the resection line. There is a debate on how much antrum has to be preserved (see above). In BPD-DS according to Marceau, the resection starts opposite to the craw foot of the vagal nerve leaving the total antrum in place. Most surgeons performing LSG as a stand-alone procedure leave only 2–4 cm of antrum in place. After inserting the bougie, the resection starts with a 6-fold linear stapler distally with a cartridge of maximal staple length as the antrum is much thicker compared to the fundus, where shorter staples will assure a safe closure of the sleeve and proper hemostasis. Stapling into the esophagus should definitely be avoided. Depending on the stapler device, it is crucial to wait until firing to allow proper compression and consecutive safe closure. In cases where the stomach is not mobile enough, staplers with angulation help avoid getting too close to the bougie at the angulus, reducing the risk of a stricture at this level. It is also crucial to avoid torsion of the sleeve, thus making sure that the staple line is always orientated opposite to the lesser curvature by lateral traction of the greater curvature. Some surgeons use buttress materials to avoid leakage or bleeding complications (see below). We oversew the staple line not only to reinforce it, but also to give the sleeve the ideal shape. If a little ear has been left at the angle of His, it can easily be plicated within the running suture. As most leakages occur at the angle of His, much less at the level of the antrum, some surgeons only oversew at the beginning and at the end of the sleeve. The resected stomach can easily be extracted in a strong plastic bag through a trocar site without the need to enlarge it. A stay suture at the distal end of the resected stomach helps to identify the narrowest part where to pull it out of the plastic bag. An inserted drain can make the management of an early leak much easier. Its use is obviously debatable. Unlike LRYGB where an intraoperative leak test is easy to perform and helps to detect small leakages, we do not believe that it is feasible and necessary in LSG.

Early Results

LSG compared to LRYGB seems to be technically less demanding, and yet there is a potential danger in this procedure: an inexperienced bariatric surgeon might not know how to manage the patient if a complication Wölnerhanssen /Peterli  

 

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Early after LSG, amelioration of glycemic control can be observed [25]. Several mechanisms contribute to this antidiabetic effect. Evidently, in the long run, weight loss and change of eating habits with reduced calorie intake are important factors. However, early after surgery, increased GLP-1 levels and decreased ghrelin levels are believed to contribute to better glycemic control which was equal in our series comparing LSG with LRYGB [7]. Although there is no doubt about the importance of these hormonal changes in achieving weight loss, recently animal models with either glp-1 receptor deficiency or ghrelin receptor deficiency showed similar effects of LSG in terms of weight loss and amelioration of glycemic control as in wild-type controls [26, 27]. These results illustrate that not the effect of one separate hormone is decisive, but much more the interaction of several gut hormones and the complex system as a whole, possibly even including some hormones that are unknown to date.

State of the Art: Sleeve Gastrectomy

is in a septic condition, surgical revision for drainage and establishment of a controlled gastrocutaneous fistula (e.g. by inserting a T-drain into the defect) may be needed. Endoscopically placed clips, fibrin glue and dilatation of the pylorus to decrease the intragastric pressure are alternatives. In cases of chronic leaks, more radical surgical treatment options have to be considered, such as total gastrectomy with a Roux-Y-esophagojejunal reconstruction or LRYGB to decrease the intragastric pressure in high leaks. In the management of any leak, an experienced bariatric surgeon should be involved from the beginning. Early dysphagia after LSG seems to be more frequent after LSG compared to LRYGB but most often resolves spontaneously as it may be caused by a certain swelling or hematoma of the submucosa [13]. Persistent strictures occur when the sleeve is too narrow from the beginning (often at the level of the angulus or at the level of a former gastric band in redo-LSG) or in case of torsion of the sleeve with rotation of the staple line. Initial watchful waiting is indicated. In case of persisting trouble, endoscopic dilatation has to be performed. Seromyotomy has been described to be an option [35], but change to an LRYGB with or without resection of the gastric remnant will finally solve the problem. Mortality of LSG seems to be equal to LRYGB (below 0.2%) [36].

Long-Term Results

Weight Loss Regarding midterm weight loss, LSG has been proven to be an effective procedure. Most studies show an EBMIL of 60% in the first 3 years after LSG [37]; longterm clinical data are limited. In a single institution examining the 5-year outcome of 49 consecutive cases (average BMI: 65, range: 39–106) with a high follow-up rate of 100%, an EBMIL of 86% could be reached [10]. In our own series of 68 consecutive cases, EBMIL was 62% after 1 year, 61% after 2, 61% after 3, 60% after 4 and 57% after 5 years (follow-up rate at 5 years: 91%). Five years postoperatively, an EBMIL of more than 50% was achieved in 55% and EBMIL over 75% in 25% [13]. These results reflect a certain learning curve as we have improved the LSG technique over the years. In the SM-BOSS trial comparing LRYGB with LSG, there was no difference regarding weight loss or EBMIL between the two groups up to 36 months after surgery with 72% EBMIL at 1 year (table 1). Dig Surg 2014;31:40–47 DOI: 10.1159/000354320

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occurs. Bleeding, leakage and stricture are the most frequent LSG-specific early complications; mesenteric vein thrombosis is a rare complication. General complications such as pulmonary embolism, pneumonia, etc. may also occur but are less frequent. In the Swiss Multicentre Bypass or Sleeve Study (SM-BOSS), a prospective randomized trial comparing LSG and LRYGB in a total of 217 patients, we could show a trend to a lower complication rate in LSG compared to LRYGB (p < 0.067) and faster OR time [14]. However, in experienced hands, the difference in OR time becomes less of an issue. The learning curve may be shorter in LSG; the conversion rate according to the literature is approximately 1% [28]. Bleeding along the staple line is rare. If the resection surface along the staple line is meticulously inspected and possible bleedings treated by argon laser beamer, and/or by oversewing the staple line, this complication can be reduced to almost zero. According to a study from 2004, the use of buttress material seems helpful in the prevention of staple line bleeding [32]. Patients on platelet aggregation inhibitors in addition to thromboembolic prophylactic heparin treatment are at increased risk for intraluminal or intra-abdominal bleeding. A drain in these cases seems to be beneficial for early detection of a postoperative bleeding complication. Leaks in LSG always occur along the staple line, in approximately 90% proximally at the angle of His, 10% in the antrum. They can be classified into acute (first 7 days after the operation), early (1–6 weeks), late (>6 weeks) and chronic (>12 weeks) leaks according to the expert panelists [28]. A narrower sleeve leads to higher intragastric pressure, which might in turn lead to an increased risk of leakage [12, 30, 31]. According to two recent systematic reviews, buttress materials are not able to reduce leakage [12, 31]. In experienced hands, the leakage rate is below 1% [14, 33], on average 1% (±1.13%) [28], going up as high as 16% in patients after LSG as a redo procedure [34]. The first clinical signs of a leak may be tachycardia, fever or pain. In most acute, early and late leaks, a conservative management should be attempted; at first with external drainage (if not already in place, CT guided) combined with absence of oral intake by either parental nutrition or radiologically guided feeding tube insertion, and if needed with antibiotics. Stenting can be an option at this early stage, but dislocation of the stent, erosion, bleeding and therapy-refractive nausea limit its use. Most often the leaks close after 4–6 weeks [28]. Surgical closure by simply oversewing the defect is not an option. If interventional drainage is not possible and the patient

Table 1. Weight loss

Table 2. Diabetes remission rate

First author

Year of Patients Follow- %EWL %EBMIL publication up, years

First author

Year of Follow-up, Remission, % publication years

Himpens [49] D’Hondt [50] Sarela [51] Kehagias [52] Rawlins [10] Sieber [13]

2010 2011 2012 2012 2013 2013

Gan [38] Vidal [39] Tsoli [40] Schauer [41] Peterli [14] Sieber [13]

2007 2008 2013 2012 2013 2013

30 23 13 21 49 68

6 5 8 5 5 5.9

53 56 68 58 86

1 1 1 1 1 5

33 85 100 37 58 85 of all patients (63 of patients on medication)

57

EWL = Excess weight loss.

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Dig Surg 2014;31:40–47 DOI: 10.1159/000354320

In our opinion, taking recent findings into account, sleeve gastrectomy can be recommended to morbidly obese, diabetic patients (table 2). Gastroesophageal Reflux Disease Preexisting severe gastroesophageal reflux disease (GERD) is generally seen as a relative contraindication for LSG [28]. Recent reviews of the literature come to controversial results: preexisting GERD seems either to worsen after LSG, but might also improve or even disappear in some patients. Other patients develop de novo GERD after surgery [42, 43]. In a concurrent cohort study carried out by Daes et al. [44], 134 patients with (49.2%) or without preexisting GERD (50.8%) received LSG and were followed for 12 months. Only 1.5% had symptoms of GERD after one year. According to the authors, this impressive reduction of GERD is the result of extra attention that was paid to removing the complete fundus, finding and correcting any hiatal hernia and preventing any narrowing or torsion of the sleeve. In our experience, we do not recommend LSG to patients with severe GERD (on chronic PPI therapy) or any signs of esophageal motility disorder, low esophageal sphincter pressure and big hiatal hernia diagnosed by routine esophageal manometry, gastroscopy and upper GI series. Nevertheless, our policy is also to prevent de novo onset of GERD, and we support the above-mentioned technical recommendations. However, our results are not that optimistic. In our series of 68 patients receiving an LSG with 5.9 years of follow-up, 34 had preoperative symptoms of reflux. Postoperatively, the rate of improvement of GERD was 56%, and new-onset GERD occurred in 16.2%. These findings are more in line with Rawlins et al. [10], who reported a GERD resolution rate of 53% and new onset in 16%. Wölnerhanssen /Peterli  

 

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Comorbidities Type 2 Diabetes Mellitus A number of studies have compared LSG with other bariatric procedures, and controversial results have been found in terms of the efficiency of LSG to ameliorate glycemic control. In 2007, Gan et al. [38] reported higher remission rates based on medication requirement for type 2 diabetes mellitus following gastric bypass (69%) compared to LSG (33%). However, the surgical technique in LSG differs largely from the technique used in our patients: in our patients the resection line started 2– 4 cm proximal to the pylorus; in Gan’s study, the whole antrum was left in situ. We hypothesize that this might lead to less acceleration of gastric emptying and thus less stimulation of GLP-1-secreting cells in the small bowel. A study from 2008 by Vidal et al. [39] showed very high remission rates of 84.6% after either gastric bypass or LSG. A recent prospective, nonrandomized study by Tsoli et al. [40] compared BPD with LSG over the course of one year and showed comparable results on oral glucose tolerance test after both procedures with a remission rate of 100% after either procedure. In a recent RCT, Schauer et al. [41] compared LSG with LRYGB and medical treatment alone in 150 obese diabetic patients with 50 patients in each arm. In this study, surgery was much more efficient than medical treatment alone, and there was no difference between LSG and LRYGB in terms of improvement of type 2 diabetes mellitus. In our own RCT comparing LRYGB and LSG, we found a remission rate of 57.7% for LSG (and 67.9% for LRYGB, difference n.s.) at one year after operation [14]. According to unpublished data by our group looking at effects on insulin secretion in detail after either operation 4 weeks after surgery, no difference was found between the two procedures.

Reoperation Definition of insufficient weight loss is difficult; diagnosis should be made with care and should always be seen in relation to (or lack of) resolution of comorbidities. One option of assessing the outcome of bariatric surgery is to apply the BAROS score by Oria; a score below 3 indicates failure [47]. Disappointed patients with exaggerated expectations regarding weight loss might want to undergo a reoperation, which should obviously be avoided. Revisional bariatric surgery is technically challenging and should be done by experienced bariatric surgeons only. Yet, in cases where remission of comorbidities is insufficient and/or secondary weight gain is seen, measures have to be taken. In our patients, insufficient weight loss leading to secondary surgery was seen in 12,000 cases. Surg Obes Relat Dis 2012;8:8–19. Weiner R, Peterli R: Laparoscopic Gastric Sleeve. Operation Primer. Berlin, Springer, 2012, vol 11. Gagner M: Leaks after sleeve gastrectomy are associated with smaller bougies: prevention and treatment strategies. Surg Laparosc Endosc Percutan Tech 2010;20:166–169. Aurora AR, Khaitan L, Saber AA: Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients. Surg Endosc 2012; 26:1509–1515.

32 Consten EC, Gagner M, Pomp A, Inabnet WB: Decreased bleeding after laparoscopic sleeve gastrectomy with or without duodenal switch for morbid obesity using a stapled buttressed absorbable polymer membrane. Obes Surg 2004;14:1360–1366. 33 Bellanger DE, Greenway FL: Laparoscopic sleeve gastrectomy, 529 cases without a leak: short-term results and technical considerations. Obes Surg 2011;21:146–150. 34 Gagniere J, Slim K, Launay-Savary MV, Raspado O, Flamein R, Chipponi J: Previous gastric banding increases morbidity and gastric leaks after laparoscopic sleeve gastrectomy for obesity. J Visc Surg 2011;148:e205–e209. 35 Dapri G, Cadiere GB, Himpens J: Laparoscopic seromyotomy for long stenosis after sleeve gastrectomy with or without duodenal switch. Obes Surg 2009;19:495–499. 36 Buchwald H, Estok R, Fahrbach K, Banel D, Jensen MD, Pories WJ, et al: Weight and type 2 diabetes after bariatric surgery: systematic review and meta-analysis. Am J Med 2009; 122:248–256 e5. 37 Deitel M, Gagner M, Erickson AL, Crosby RD: Third International Summit: current status of sleeve gastrectomy. Surg Obes Relat Dis 2011;7:749–759. 38 Gan SS, Talbot ML, Jorgensen JO: Efficacy of surgery in the management of obesity-related type 2 diabetes mellitus. ANZ J Surg 2007;77: 958–962. 39 Vidal J, Ibarzabal A, Romero F, Delgado S, Momblan D, Flores L, et al: Type 2 diabetes mellitus and the metabolic syndrome following sleeve gastrectomy in severely obese subjects. Obes Surg 2008;18:1077–1082. 40 Tsoli M, Chronaiou A, Kehagias I, Kalfarentzos F, Alexandrides TK: Hormone changes and diabetes resolution after biliopancreatic diversion and laparoscopic sleeve gastrectomy: a comparative prospective study. Surg Obes Relat Dis 2013;9:667–677. 41 Schauer PR, Kashyap SR, Wolski K, Brethauer SA, Kirwan JP, Pothier CE, et al: Bariatric surgery versus intensive medical therapy in obese patients with diabetes. N Engl J Med 2012;366:1567–1576. 42 Chiu S, Birch DW, Shi X, Sharma AM, Karmali S: Effect of sleeve gastrectomy on gastroesophageal reflux disease: a systematic review. Surg Obes Relat Dis 2011;7:510–515. 43 Mahawar KK, Jennings N, Balupuri S, Small PK: Sleeve gastrectomy and gastro-oesophageal reflux disease: a complex relationship. Obes Surg 2013;23:987–991. 44 Daes J, Jimenez ME, Said N, Daza JC, Dennis R: Laparoscopic sleeve gastrectomy: symptoms of gastroesophageal reflux can be reduced by changes in surgical technique. Obes Surg 2012;22:1874–1879. 45 Gehrer S, Kern B, Peters T, Christoffel-Courtin C, Peterli R: Fewer nutrient deficiencies after laparoscopic sleeve gastrectomy (LSG) than after laparoscopic Roux-Y-gastric bypass (LRYGB) – a prospective study. Obes Surg 2010;20:447–453.

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6 Regan JP, Inabnet WB, Gagner M, Pomp A: Early experience with two-stage laparoscopic Roux-en-Y gastric bypass as an alternative in the super-super obese patient. Obes Surg 2003;13:861–864. 7 Peterli R, Steinert RE, Woelnerhanssen B, Peters T, Christoffel-Courtin C, Gass M, et al: Metabolic and hormonal changes after laparoscopic Roux-en-Y gastric bypass and sleeve gastrectomy: a randomized, prospective trial. Obes Surg 2012;22:740–748. 8 Weiner RA, Weiner S, Pomhoff I, Jacobi C, Makarewicz W, Weigand G: Laparoscopic sleeve gastrectomy – influence of sleeve size and resected gastric volume. Obes Surg 2007; 17:1297–1305. 9 Atkins ER, Preen DB, Jarman C, Cohen LD: Improved obesity reduction and co-morbidity resolution in patients treated with 40-French bougie versus 50-French bougie four years after laparoscopic sleeve gastrectomy. Analysis of 294 patients. Obes Surg 2012;22:97–104. 10 Rawlins L, Rawlins MP, Brown CC, Schumacher DL: Sleeve gastrectomy: 5-year outcomes of a single institution. Surg Obes Relat Dis 2013;9:21–25. 11 Parikh M, Gagner M, Heacock L, Strain G, Dakin G, Pomp A: Laparoscopic sleeve gastrectomy: does bougie size affect mean %EWL? Short-term outcomes. Surg Obes Relat Dis 2008;4:528–533. 12 Parikh M, Issa R, McCrillis A, Saunders JK, Ude-Welcome A, Gagner M: Surgical strategies that may decrease leak after laparoscopic sleeve gastrectomy: a systematic review and meta-analysis of 9991 cases. Ann Surg 2013; 257:231–237. 13 Sieber P, Gass M, Kern B, Peters T, Slawik M, Peterli R: Five-year results of laparoscopic sleeve gastrectomy. Surg Obes Relat Dis 2013, Epub ahead of print. 14 Peterli R, Borbély Y, Kern B, Gass M, Peters T, Thurnheer M, et al: Early results of the Swiss Multicentre Bypass Or Sleeve Study (SM-BOSS): a prospective randomized trial comparing laparoscopic sleeve gastrectomy and Roux-Y-gastric bypass. Ann Surg 2013; 258:690–694; discussion 695. 15 Michalsky D, Dvorak P, Belacek J, Kasalicky M: Radical resection of the pyloric antrum and its effect on gastric emptying after sleeve gastrectomy. Obes Surg 2013;23:567–573. 16 Baumann T, Kuesters S, Grueneberger J, Marjanovic G, Zimmermann L, Schaefer AO, et al: Time-resolved MRI after ingestion of liquids reveals motility changes after laparoscopic sleeve gastrectomy – preliminary results. Obes Surg 2011;21:95–101. 17 Melissas J, Leventi A, Klinaki I, Perisinakis K, Koukouraki S, de Bree E, et al: Alterations of global gastrointestinal motility after sleeve gastrectomy: a prospective study. Ann Surg 2013;258:976–982. 18 Dimitriadis E, Daskalakis M, Kampa M, Peppe A, Papadakis JA, Melissas J: Alterations in gut hormones after laparoscopic sleeve gas-

State of the Art: Sleeve Gastrectomy

48 Himpens J, Dapri G, Cadiere GB: A prospective randomized study between laparoscopic gastric banding and laparoscopic isolated sleeve gastrectomy: results after 1 and 3 years. Obes Surg 2006;16:1450–1456. 49 Himpens J, Dobbeleir J, Peeters G: Long-term results of laparoscopic sleeve gastrectomy for obesity. Ann Surg 2010;252:319–324. 50 D’Hondt M, Vanneste S, Pottel H, Devriendt D, Van Rooy F, Vansteenkiste F: Laparoscopic sleeve gastrectomy as a single-stage procedure for the treatment of morbid obesity and the resulting quality of life, resolution of comorbidities, food tolerance, and 6-year weight loss. Surg Endosc 2011;25:2498–2504.

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51 Sarela AI, Dexter SP, O’Kane M, Menon A, McMahon MJ: Long-term follow-up after laparoscopic sleeve gastrectomy: 8–9-year results. Surg Obes Relat Dis 2012;8:679–684. 52 Kehagias I, Spyropoulos C, Karamanakos S, Kalfarentzos F: Efficacy of sleeve gastrectomy as sole procedure in patients with clinically severe obesity (BMI ≤50 kg/m2). Surg Obes Relat Dis 2012;9:363–369.

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46 Moize V, Andreu A, Flores L, Torres F, Ibarzabal A, Delgado S, et al: Long-term dietary intake and nutritional deficiencies following sleeve gastrectomy or Roux-en-Y gastric bypass in a Mediterranean population. J Acad Nutr Diet 2013;113:400–410. 47 Oria HE, Moorehead MK: Bariatric analysis and reporting outcome system (BAROS). Obes Surg 1998;8:487–499.

State of the art: sleeve gastrectomy.

In the biliopancreatic diversion (BPD) type duodenal switch, sleeve gastrectomy was applied as the restrictive part instead of a horizontal gastrectom...
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