Indications for sleeve gastrectomy
Similar to the fact that obesity is a multifactorial disease, success after bariatric surgery is also multifactorial. Behavioral changes may be just as important as the choice of a specific bariatric operation in determining the long- term success or failure of the procedure. This makes it practically impossible to compare the results of these operations and complicates the determination of specific indications and preferences.
In addition to the existing controversies, the definition of success after bariatric surgery remains an area of disagreement. Some may consider normalization of body mass index (BMI) as the definition of success, while others believe that a 50% reduction in excess body weight would be sufficient.
What is interesting in bariatric surgery is that patients may have goals different from those of their surgeons. Many base their success on improvement in quality of life, resolution of comorbidities, or simply on a sense of well- being, which may not require such significant weight loss as surgeons may aim for.
In a field under close scrutiny such as bariatric surgery, many patients primarily seek safety and place it above effectiveness. They tend to look for a “simple” concept that they can easily understand and avoid complex procedures that they perceive as more risky, even if this is not supported by evidence. Surveys have shown that fear is the main reason why patients do not seek bariatric surgery.
For these reasons, sleeve gastrectomy has rapidly gained popularity and has become a leader among commonly performed bariatric operations. Patients favor restricting the stomach with an operation that does not cause major changes in intestinal anatomy (in contrast to gastric bypass), with a simple concept of reducing stomach size while preserving metabolic effects as a result of removal of the gastric fundus (in contrast to gastric banding, which is safe and simple but preserves the ghrelin-producing zone).
In addition to the fact that reduction of the stomach is a popular concept, we will consider several other indications that contribute to the choice of sleeve gastrectomy compared to other operations:
1. Young patients and individuals older than 60 years.
In young patients with severe comorbidities and an expected longer life expectancy, the choice of sleeve gastrectomy is partly associated with the fact that there is a lower number of long-term metabolic complications related to malabsorption compared to other methods (gastric bypass — RYGB or biliopancreatic diversion — BPD-DS).
In addition, since we consider obesity a chronic progressive disease, these young patients, despite all efforts, may continue to gain weight as they age. This is especially true in the case of certain social, economic, and other changes, such as future pregnancy. The presence of sleeve gastrectomy would be ideal for performing a second-stage operation of a malabsorptive nature in the future in these patients.
In elderly patients, who usually have higher morbidity and mortality, laparoscopic sleeve gastrectomy (LSG) is characterized by shorter operative time, faster recovery, and a lower level of complications.
2. Use of sleeve gastrectomy as a revision operation
in case of ineffectiveness of a previous technique, such as gastric banding. This, however, remains a controversial issue, and the choice of revision should be based on the surgeon’s skills and disease history, as well as on the current anatomy.
3. Intraoperative indications for sleeve gastrectomy
in the presence of anatomical findings that prevent or complicate another bariatric operation: an example is reversed arrangement of internal organs.
Also, an indication for sleeve gastrectomy may be sharply increased central distribution of intra-abdominal fat, which makes gastrointestinal anastomosis risky when attempting to bring the small intestine to the gastric stump.
That is why it is extremely important to evaluate the feasibility of surgery in these more complex patients before dividing the intestine and attempting a malabsorptive operation.
Problems with anesthesia in these high-risk patients (high peak airway pressure, problems with hemodynamics, etc.) may be an indication for conversion to a shorter and simpler operation.
4. Previous operations
may make it difficult to perform gastric bypass or duodenal bypass (RYGB, DS) even in the hands of specialists due to dense or deep adhesions in the pelvic region.
This is a complex task, since it requires accurate measurement of the length of the intestine in addition to correct orientation of the intestine before division and anastomosis.
The advantage of sleeve gastrectomy is that the operative field is limited to the upper part of the abdomen, and the presence of any other adhesions in the omentum or intestine can be disregarded.
5. Patients with high surgical risk
due to severe comorbidities such as cardiac or respiratory failure will certainly benefit from this method, since it is simpler and requires less operative time.
6. Sleeve gastrectomy is indicated in young women of reproductive age with expected pregnancy.
Bariatric surgery contributes to an increase in the frequency of pregnancy occurrence.
This is due to the fact that obesity is associated, in particular, with menstrual disorders, abortions, anovulation, and infertility.
In addition, obesity is associated with complications during pregnancy such as gestational hypertension, preeclampsia, gestational diabetes mellitus, thrombosis and thromboembolism, dystocia, higher frequency of cesarean section, and fetal macrosomia.
Some studies have shown that bariatric operations associated with malabsorption represent an important congenital risk of nutritional deficiency, especially biliopancreatic diversion (BPD-DS), whereas gastric bypass (RYGB) represents a lower risk.
Due to the low deficiency of nutrients in sleeve gastrectomy, this technique has a higher chance of success in ensuring and maintaining an uncomplicated pregnancy.
7. Sleeve gastrectomy is indicated in patients with gastric pathology requiring long-term endoscopic surveillance.
This indication is evident in patients living in endemic regions with a risk of gastric cancer, such as Japan, Chile, Colombia, or other regions.
Performing gastric bypass or biliopancreatic diversion will prevent subsequent endoscopic surveillance of the remaining part of the stomach through the residual gastric tube.
8. Sleeve gastrectomy is indicated in patients who require long-term anticoagulant therapy.
This is based on the fact that with methods such as RYGB or BPD-DS, anastomotic ulcers may occur.
The risk of bleeding from them in this type of patients is higher, therefore they would benefit from using a technique that does not require anastomosis, such as LSG.
In addition, absorption of anticoagulants is improved.
9. Sleeve gastrectomy is more indicated in smoking patients.
Smoking itself represents a risk factor for patients.
In addition, the relationship between smoking and damage to the gastric mucosa is well known.
Smoking exposes postoperative outcomes in patients who have undergone bariatric surgery to risk and increases the frequency of complications.
To optimize and reduce postoperative complications, the patient is recommended to stop smoking before performing bariatric surgery.
Since this habit is difficult to overcome, in smokers in the hierarchy of bariatric operations, LSG is more acceptable in order to avoid complications associated with anastomotic ulcers, and these patients are easier to prepare in the preoperative period.
Since in preoperative preparation it is desirable to achieve a period without tobacco use for 1 year for RYGB and 3 months for LSG.
10. Patients who require other non-bariatric operations:
for example, repair of postoperative hernia or organ transplantation.
Prior weight loss in patients with obesity who must undergo these procedures allows for better outcomes.
Thus, reduction of intra-abdominal fat or liver size contributes to a more favorable performance of other non-bariatric operations.
Contraindications and limitations of sleeve gastrectomy
A fundamental factor of any bariatric surgery is the maintenance of long-term weight loss. Some surgeons believe that this is a weak point of sleeve gastrectomy, because dilation of the remaining part of the stomach is always a problem for both surgeons and patients during long-term follow-up.
Since this is a restrictive procedure, it may lose its effectiveness if the stomach increases in size over several years after the operation. This is especially true for poorly performed gastric sleeves with preservation of the fundus, which may gradually dilate, causing severe symptoms of gastroesophageal reflux disease (GERD) and, ultimately, weight regain.
1. Patients with severe metabolic syndrome, especially with type 2 diabetes mellitus (T2DM), achieve greater effect when RYGB and BPD-DS are performed compared to LSG.
Although LSG is effective in the short-term and mid-term (1–3 years), RYGB appears to have the most favorable risk-benefit ratio.
2. It is recommended to always eliminate hiatal hernia if it exists. The presence of a hiatal hernia itself is not a contraindication to sleeve gastrectomy if it is identified and corrected, but a large paraesophageal hernia is considered a contraindication by most authors.
Patients with severe reflux should not be assigned sleeve gastrectomy.
Some authors do not consider gastroesophageal reflux disease (GERD) an absolute contraindication to sleeve gastrectomy, although this aspect remains controversial and requires long-term follow-up studies.
GERD has been described “de novo” in patients after sleeve gastrectomy. This is associated with many factors such as the formation of a high-pressure gastric tube and “flattening” of the angle of His.
Rebecchi et al. believe that in patients without previous evidence of GERD, the occurrence of de novo reflux is rare.
The authors recommend obtaining objective data to accurately determine acid exposure in distal segments, since there is a significant discrepancy between subjective and objective findings in patients with heartburn.
It is believed that technical problems such as missed hiatal hernia, preservation of the gastric fundus, narrow or angulated sleeve formation are often the causes of many GERD problems after sleeve gastrectomy.
A well-constructed sleeve providing optimal weight loss in the absence of hiatal hernia usually does not cause GERD.
Therefore, we do not consider GERD a contraindication to this operation.
3. Although the incidence of Barrett’s esophagus is low (1.3%), this should be taken into account.
While esophageal cancer overall remains rare despite increased risk, the loss of the ability to perform gastric pull-up after esophagectomy forces surgeons to use the colon, which makes this operation more complex and associated with higher complications; therefore, most surgeons still consider Barrett’s esophagus an absolute contraindication.
TECHNICAL ASPECTS AND ADVANTAGES
There are certain aspects that make this procedure more attractive compared to others.
The feasibility and safety of sleeve gastrectomy have been widely studied. It does not use implants such as adjustable gastric banding, which provides an advantage in terms of infections and erosions.
Some authors report that a shorter learning curve is required. We believe this is true, but we are also firmly convinced that although this is an “easier” operation that does not require suturing skills, it should not be taken lightly.
Technical shortcomings may lead to catastrophic consequences such as chronic staple line failure, refractory reflux due to a retained gastric fundus, or chronic dysphagia due to a twisted gastric sleeve.
From an economic perspective, it is potentially associated with lower cost due to shorter hospital stay in some centers compared to other procedures, as well as a lower complication rate (many long-term complications do not occur with sleeve gastrectomy, such as internal hernias, anastomotic ulcers, etc.).
CONCLUSION
Laparoscopic sleeve gastrectomy is a safe and effective metabolic operation that has taken a well-deserved place among all available options.
In the right hands and with proper indications, sleeve gastrectomy should become the first-line operation in the management of the chronic progressive disease of obesity.
