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Figure (1)
AIM OF WORK
The aim of this work is to compare short term changes in volume and
anatomy of the stomach following laparoscopic sleeve gastrectomy
versus laparoscopic gastric plication and comparing the effect of both
procedures on the clinical outcome and weight loss of the patients.
REVIEW OF LITERATURE
ANATOMY OF THE STOMACH
The stomach is readily recognizable as the asymmetrical, pearshaped, most proximal abdominal organ of the digestive tract (Fig. 2)
(Mercer et al., 2002). The part of the stomach attached to the esophagus
is called the cardia. Just proximal to the cardia at the gastro-esophageal
(GE) junction is the anatomically indistinct but physiologically
demonstrable lower esophageal sphincter. At the distal end, the pyloric
sphincter connects the stomach to the proximal duodenum. The stomach
is relatively fixed at these points, but the large mid-portion is quite
mobile (Ashley et al., 1999).
Figure 2
angularis incisura, the lesser curvature turns rather abruptly to the right,
marking the anatomic beginning of the antrum, which comprises the
distal 25 to 30% of the stomach (Ashley et al., 1999).
Acid Secretion:
Hydrochloric acid in the stomach hastens both the physical and
(with pepsin) the biochemical breakdown of ingested food. In an acidic
environment, pepsin and acid facilitate proteolysis. Gastric acid also
inhibits the proliferation of ingested pathogens, which protects against
both infectious gastroenteritides and intestinal bacterial overgrowth.
Long-term acid suppression with proton pump inhibitors (PPIs) has been
associated with an increased risk of community acquired Clostridium
difficile colitis and other gastroenteritides, presumably because of the
absence of this protective germicidal barrier (Cadle et al., 2007).
Gastric Hormones:
Gastrin:
Gastrin is produced by antral G cells and is the major hormonal
stimulant of acid secretion during the gastric phase. Gastrin is also trophic
to GI epithelial and enterochromaffin cells. A variety of molecular forms
exist: big gastrin (34 amino acids; G34), little gastrin (17 amino acids;
G17), and minigastrin (14 amino acids; G14). The large majority of
gastrin released by the human antrum is G17. The biologically active
7
Somatostatin:
Somatostatin is produced by D cells located throughout the gastric
mucosa. The predominant form in humans is somatostatin 14, though
somatostatin 28 is present as well. The major stimulus for somatostatin
release is antral acidification; acetylcholine from vagal nerve fibers
inhibits its release. Somatostatin inhibits acid secretion from parietal cells
and gastrin release from G cells. It also decreases histamine release from
ECL cells. The proximity of the D cells to these target cells suggests that
the primary effect of somatostatin is mediated in a paracrine fashion, but
an endocrine (i.e., bloodstream) effect also is possible (Johnson et al.,
2006).
Gastrin-releasing peptide:
GRP is the mammalian equivalent of bombesin, a hormone
discovered more than two decades ago in an extract of skin from a frog.
In the antrum, GRP stimulates both gastrin and somatostatin release by
binding to receptors on the G and D cells. There are nerve terminals
ending near the mucosa in the gastric body and antrum, which are rich in
GRP immunoreactivity. When GRP is given peripherally, it stimulates
acid secretion, but when it is given centrally into the cerebral ventricles of
animals, it inhibits acid secretion, apparently via a pathway involving the
sympathetic nervous system. GRP is a mediator of gastroprotective
increased mucosal blood flow in response to luminal irritants (Del Valle
et al., 2003).
Leptin:
Leptin is a protein primarily synthesized in adipocytes. It is also
made by chief cells in the stomach, the main source of leptin in the GI
tract (Cummings et al., 2007). Leptin works at least in part via vagally
mediated pathways to decrease food intake in animals. Not surprisingly,
leptin, a satiety signal hormone, and ghrelin, a hunger signal hormone,
are both primarily synthesized in the stomach, an organ increasingly
recognized as central to the mechanisms of appetite control. (Badman et
al., 2007).
Ghrelin:
Ghrelin is secreted by the endocrine cells of the stomach (X/A-like
cells) which reside in the oxyntic glands of the gastric fundus. Gastric
ghrelin producing cells are in contact with the basement membrane
adjacent to the blood stream and most of them do not come in contact
9
by
the
activation
of
ghrelin
receptors
in
the
10
Figure 3
Resection of the primary source of this hormone (i.e., the stomach)
may partly account for the anorexia and weight loss seen in some patients
following gastrectomy (Figure 3) (Ariyasu et al., 2001). The gastric
bypass operation, a very effective treatment for morbid obesity, has been
shown by some investigators to be associated with suppression of plasma
ghrelin levels (and appetite) in humans (Cummings et al., 2002). Other
groups have failed to show a significant decrease in ghrelin levels
following gastric bypass but have found such decreases following sleeve
gastrectomy, another effective weight loss operation (Karamanakos et
al., 2008). Obviously appetite control is complex with redundant and
overlapping
orexigenic
and
anorexigenic
pathways
and
signals
Gastric Emptying:
The control of gastric emptying is complex. In general, gastric
emptying is slowed by increasing caloric content or osmolarity, increased
fat content, and increased particle size; liquid emptying is faster than
solid emptying. Osmolarity, acidity, caloric content, and nutrient
composition are important modulators. Stimulation of duodenal
osmoreceptors, glucoreceptors, and pH receptors clearly inhibits gastric
emptying by a variety of neurohumoral mechanisms. Cholecystokinin
(CCK) has been consistently shown to inhibit gastric emptying at
physiologic doses. Recently, it has been noted that the anorexigenic
hormone leptin, secreted mostly by fat but also by gastric mucosa,
inhibits gastric emptying, perhaps through the same pathway as CCK
(which also has properties of a satiety hormone). The orexigenic hormone
ghrelin has the opposite effect (Wolfe et al., 1988).
12
Liquid Emptying:
The gastric emptying of water or isotonic saline follows first-order
kinetics, with a half emptying time around 12 minutes. Thus, if one
drinks 200 ml of water, about 100 ml enters the duodenum by 12 minutes,
whereas if one drinks 400 ml of water, about 200 ml enters the duodenum
by 12 minutes. This emptying pattern of liquids is modified considerably
as the caloric density, osmolarity, and nutrient composition of the liquid
changes. Up to an osmolarity of about 1 M, liquid emptying occurs at a
rate of about 200 kcal per hour. Duodenal osmoreceptors and hormones
(e.g., secretin and vasoactive intestinal peptide (VIP)) are important
modulators of liquid gastric emptying. Generally, liquid emptying is
delayed in the supine position (Feldman et al., 2002).
Traditionally, liquid emptying has been attributed to the activity of
the proximal stomach, but it is probably more complicated than
previously
thought.
Clearly,
receptive
relaxation
and
gastric
this distal gastric activity appears to vary with the nutrient composition
and caloric content of the liquid meal. Depending on the circumstances,
distal gastric motor activity can promote or inhibit gastric emptying of
liquids. Distal gastrectomy and pyloric stenting both obviously interfere
with distal gastric motor activity, and both accelerate the initial rapid
phase of liquid gastric emptying (Feldman et al., 2002).
Solid Emptying:
Normally, the half-time of solid gastric emptying is <2 hours.
Unlike liquids, which display an initial rapid phase followed by a slower
linear phase of emptying, solids have an initial lag phase during which
little emptying of solids occurs. It is during this phase that much of the
grinding and mixing occurs. A linear emptying phase follows, during
which the smaller particles are metered out to the duodenum. Solid
gastric emptying is a function of meal particle size, caloric content, and
composition (especially fat). When liquids and solids are ingested
together, the liquids empty first. Solids are stored in the fundus and
delivered to the distal stomach at constant rates for grinding. Liquids also
are sequestered in the fundus, but they appear to be readily delivered to
the distal stomach for early emptying. The larger the solid component of
the meal, the slower the liquid emptying. Patients bothered by dumping
syndrome are advised to limit the amount of liquid consumed with the
solid meal, taking advantage of this effect. Three prokinetic agents are
commonly used to treat delayed gastric emptying (Ashley et al., 1999).
14
DIAGNOSTIC TESTS
Esophagogastroduodenoscopy:
Esophagogastroduodenoscopy (EGD) is a safe and accurate
outpatient procedure performed under conscious sedation. Smaller
flexible scopes with excellent optics and a working channel are easily
passed transnasally in the unsedated patient. Following an 8-hour fast, the
flexible scope is advanced under direct vision into the esophagus,
stomach, and duodenum. The fundus and GE junction are inspected by
retroflexing the scope. To rule out cancer with a high degree of accuracy,
all patients with gastric ulcer diagnosed on upper GI series or found at
EGD should have multiple biopsies of the base and rim of the lesion.
Brush cytology also should be considered. Gastritis should be biopsied
both for histological examination and for a tissue urease test to rule out
the presence of H. pylori. If Helicobacter infection is detected, it should
probably be treated because of the etiologic association with peptic
ulcers, mucosa-associated lymphoid tissue (MALT), and gastric cancer.
The most serious complications of EGD are perforation (which is rare,
but can occur anywhere from the cervical esophagus to the duodenum),
aspiration, and respiratory depression from excessive sedation. Although
EGD is a more sensitive test than double-contrast upper GI series, these
modalities should be considered complementary rather than mutually
exclusive (Marks et al., 2007).
Radiological Tests:
Plain abdominal x-rays may be helpful in the diagnosis of gastric
perforation (pneumoperitoneum) or delayed gastric emptying (large airfluid level) (Harbison et al., 2005).
15
Endoscopic Ultrasound:
Endoscopic ultrasound (EUS) is useful in the evaluation and
management of some gastric lesions. Local staging of gastric
adenocarcinoma with EUS is quite accurate, and this modality can be
used to plan therapy. At some centers, patients with transmural and/or
node positive adenocarcinoma of the stomach are considered for
preoperative (neoadjuvant) chemoradiation therapy. EUS is the best way
to clinically stage these patients locoregionally. Suspicious nodes can be
sampled with EUS-guided endoscopic needle biopsy. Malignant tumors
that are confined to the mucosa on EUS may be amenable to endoscopic
mucosal resection (EMR). EUS also can be used to assess tumor response
to chemotherapy. Submucosal masses are commonly discovered during
routine EGD. Large submucosal masses should be resected because of the
risk of malignancy, but observation may be appropriate for some small
submucosal masses (e.g., lipoma or small gastro-intestinal stromal tumor
(GIST)). There are endoscopic characteristics of benign and malignant
mesenchymal tumors, and thus, EUS can provide reassurance, but no
guarantee, that small lesions under observation are probably benign.
Submucosal varices also can be assessed by EUS (Caddy et al., 2007).
17
and PPIs should be withheld for a week before gastric analysis (Balaji et
al., 2002).
Scintigraphy:
Nuclear medicine tests can be helpful in the evaluation of gastric
emptying and duodenogastric reflux. The standard scintigraphic
evaluation of gastric emptying involves the ingestion of a test meal with
one or two isotopes, and scanning the patient under a gamma camera. A
curve for liquid and solid emptying is plotted, and the half-time
calculated. Normal standards exist for each facility. Duodenogastric
reflux can be quantitated by the IV administration of hepatobiliary
iminodiacetic acid, which is concentrated and excreted by the liver into
the duodenum. Software allows a semiquantitative assessment of how
much of the isotope refluxes into the stomach. Positron emission
tomography (PET) scan or CT/PET scan may be useful in certain patients
with gastric malignancy (Chen et al., 2005).
19
improvement
in
blood
pressure
with
elimination
of
20
21
Types :
Two primary strategies of surgically induced weight loss have
arisen over the past 50 years: gastric restriction and intestinal
malabsorption. Some procedures combine elements of restriction and
malabsorption. The restrictive procedures cause early satiety by creation
of a small gastric pouch and prolong satiety by creation of a small outlet
to that pouch. Restrictive procedures include many varieties of
gastroplasty and gastric banding. In these procedures, the outlet is
reinforced by prosthetic material to prevent dilatation. The pouch and the
outlet must be small enough to adequately restrict intake, yet not so small
as to cause obstruction. Adjustable gastric banding systems allow for fine
adjustment of the outlet diameter, which may offset the disadvantages of
a fixed nonadjustable outlet (Schauer and Ikramuddin, 2001).
Malabsorptive procedures in use today include the biliopancreatic
diversion (BPD), with or without duodenal switch, and the distal gastric
bypass (DGBP). These procedures involve some degree of gastric volume
reduction, but primarily depend on bypass of various lengths of small
intestine to cause malabsorption akin to a controlled short-gut
syndrome. The degree of malabsorption is determined by the length of
22
Gastric Restriction:
Gastric restriction mechanically prevents the patient from
overeating by a mechanism similar to an hourglass. Satiety is caused by
creation of a small gastric pouch and prolonged by a small outlet, often
reinforced by prosthetic material to prevent dilation. They involve
surgical manipulation of the stomach only and thus are considered
straightforward from a technical standpoint. They also carry a low risk of
postoperative nutritional disturbances. Significant dietary compliance is
required because the intake of high-calorie liquids or soft foods is not
inhibited by the narrow outlet and will result in a failure to lose weight.
Gastric restrictive procedures sometimes require subsequent surgical
revisions due to failure (Mason, 1982).
Figure 4
Vertical Banded Gastroplasty
curve of the stomach and the left gastric artery along the gastric wall
entering the lesser sac and exiting at the angle of His. This so-called
perigastric technique has been associated with a higher rate of slippage of
the posterior wall of the stomach through the band (posterior slippage)
and is no longer recommended (Khoursheed et al., 2007).
The recommended technique is commonly called the pars
flaccida technique and initially involves dissecting the left lateral aspect
of the gastroesophageal pad of fat. The gastrohepatic membrane is then
opened visualizing the base of the right crus, and blunt dissection is made
through the retroperitoneal fat superiorly and to the left. This retrogastric
tunnel exits the retroperitoneal fat just posterior to the angle of His near
the superior pole of the spleen. Once the retrogastric tunnel is dissected, a
band of appropriate size is selected, inserted into the abdomen, and pulled
through the retrogastric tunnel. A buckling mechanism on the band is then
engaged. The fundus of the stomach is then plicated over the lateral
aspect of the band with 3 interrupted sutures to minimize the risk of
anterior band slippage, and the tubing is pulled through 1 of the
laparoscopic ports. The subcutaneous port is then attached to the tubing
and the port is fixed to the abdominal wall fascia in a position that will
facilitate future percutaneous access using a non-coring needle (Figure 5)
(OBrien et al., 2005).
27
Figure 5
Adjustable Gastric Banding
Malabsorption:
Malabsorptive techniques involve creating a bypass of the small
intestine to produce a controlled short-bowel syndrome, causing
malabsorption of ingested nutrients and subsequent weight loss. Weight
reduction is reliable and superior to that of gastric restriction. However, a
higher risk of peri-operative complications and postoperative nutritional
deficiencies are inevitable consequences of these major rearrangements in
the anatomy and physiology of the upper gastrointestinal tract
(Scopinaro, 1979).
31
Figure 6
Roux-en-Y Gastric Bypass
mesentery. One concern about the ante-colic position is the potential for
increased tension at the gastrojejunostomy with resultant increased
ischemic stricture and possible leak rate (Bertucci et al., 2005).
This has not been shown to occur in retrospective studies, however,
the retrocolic path is shorter but requires creation of a transverse
mesocolic defect. One proposed benefit of the antecolic orientation is
lack of internal hernia formation through the transverse mesocolon
(Taylor et al., 2006).
Retrospective studies have shown that the antecolic position does
not protect against internal herniation due to hernias through the large
Peterson hernia defect space (Carmody et al., 2005).
The construction of the gastrojejunostomy is yet another area of
debate and again is likely more a matter of surgeon preference. Current
techniques include circular stapled, linear stapled, or completely
handsewn anastomoses. When the circular stapler is used, the anvil can
be introduced either by mouth or transabdominally. With the linear
stapled technique, the closure of the common enterotomy can be stapled
or handsewn. Again, there have been no randomized trials comparing any
of these techniques; however, there are studies to support each procedure
equally when considering operative time, leak rate, and stenosis (AbdelGalil et al., 2002).
One potential down side of the circular stapled technique is
increased risk of wound infection, which is reported to be as high as 10%.
It is believed that the rate of infection has been lowered by the use of a
laparoscopic entrapment sac to cover the end of the stapler before
removal as well as to house the transected small bowel segment for
removal (Podnos et al., 2003).
33
34
37
38
Figure 7
Bilio-pancreatic diversion
39
40
41
Figure 8
LSG is performed for morbid obesity with the patient in the supine
position on a split-leg operating table. The surgeon stands between the
42
patients legs with the first and second assistants on the patients right and
left sides, respectively (Figure 9). Under general anesthesia, the
procedure is begun with open entry into the abdomen through an incision
at the umbilicus. A 5- to 12-mm port is placed and pneumoperitoneum is
achieved with carbon dioxide to 15 mm Hg. Six additional ports are
placed under direct vision a 5- to 12-mm port is placed in the right upper
quadrant for liver retraction and an additional (optional) 5- to 12-mm port
is placed in the midepigastrium for visualization of the hiatus. Two 15mm disposable working ports are placed in the right and left
midepigastrium and a 5- to 12-mm disposable working port is placed in
the high epigastrium. Finally, a 5-mm reusable port is placed in the left
lower quadrant for lateral gastric retraction.
In steep reverse Trendelenburg position, dissection begins with
opening of the greater omentum using an ultrasonic dissector (Harmonic;
Ethicon Endosurgery, Cincinnati, OH, USA) or Ligasure (Autosuture
Bariatrics/Covidien) along the greater curvature of the stomach
approximately 4 to 6 cm proximal to the pylorus. The dissection
continues cephalad to the gastroesophageal junction and the left crus. The
short gastric vessels are ligated carefully and care is taken to avoid injury
to the spleen.
The left crus is completely freed of any attachments to avoid
leaving a posterior pouch when constructing the sleeve in this region. The
dissection is completed by freeing any posterior attachments of the
stomach to the pancreas. This is performed with sharp dissection to avoid
thermal injury to the pancreas or the lesser curvature of the stomach.
Gastric transection begins 4 to 6 cm proximal to the pylorus
(Figure
9). A 60-mm,
4.8-mm,
43
endo-GIA stapler
(Autosuture
Figure 9
Sequential firings of the stapler along the border of the bougie on
the lesser curvature completes the gastric transection at the left crus. After
completing the transection, the entire staple line is inspected carefully to
44
make sure that the staples are well formed especially at the antrum where
the stomach is thickest. The transected stomach then is removed using a
specimen collection bag (EndoCatch; Autosuture Bariatrics/Covidien)
placed through one of the 15-mm port sites or by enlarging the umbilical
incision. After completion of the gastric transection the integrity of the
staple line is tested. The pylorus is compressed with a surgical grasper.
Methylene blue is injected into the stomach (throught the bougie) and the
staple line is inspected carefully for leak. The methylene blue then is
removed from the stomach, as is the bougie. All trocar sites are closed
with 0 Vicryl (Ethicon) using a suture passer to prevent abdominal wall
hernias (Almogy et al., 2004).
also dissected to allow optimal freedom for creating and sizing the
invagination properly. The next step was to initiate gastric plication by
imbricating the greater curvature over a 32-Fr bougie and applying a first
row of extra-mucosal interrupted stitches of 2-0 Ethibond sutures
(Figure 11). This row guided two subsequent rows created with extramucosal running suture lines of 2-0 Prolene. The reduction resulted in
a stomach shaped like a large sleeve gastrectomy (Ramos et al., 2010).
Figure 10
Fig. 1 Trocar position: a. 10mm above the umbilicus slightly to the
right; b. 10mm in URQ; c. 5mm below xiphoid's appendices; d. 5mm
in the ULQ; e. 5mm on the URQ at the axilary line (Ramos et al., 2010)
46
Figure 11
Advantages of Sleeve:
As the global population continues to suffer from increasing
obesity, surgeons have begun devising safer methods for the management
of these patients. By performing less invasive procedures as the initial
part of a two-staged surgical regimen, complications and mortality can be
kept to a minimum (Nguyen et al., 2005). Some surgeons have begun
using SG as solitary therapy for the treatment of morbid obesity. This is
because of the lack of need for foreign material, excellent patient
tolerance by maintenance of gastric emptying, and decreased incidence of
nutritional deficiencies (Catheline et al., 2006).
A study of 23 patients, not included in this analysis, found that
after SG, stomach contents actually empty rapidly into the small
intestines casting doubt as to whether this procedure is truly restrictive
and underscoring the possibility that gut hormonal alterations may play a
larger role in satiety and weight loss than currently appreciated (Melissas
et al., 2007).
48
Advantages of Plication:
Laparoscopic Gastric Plication is a bariatric procedure that brings
together the benefits of food restriction without the possible
complications associated with a permanent implant while also
minimizing the possibility of leaks from the rupture of staple lines is
highly desirable and may be a preferred alternative restrictive procedure
for some patients. LGCP is notably similar to a VSG in that it generates a
gastric tube by means of eliminating the greater curvature but does so
without gastric resection. It is likely that LGCP greatly reduces the
possibility for gastric leaks. Talebpour and Amoli report one case of a
gastric leak associated with a more aggressive version of LGCP, which
the authors attributed to excessive vomiting in the early postoperative
period (Ramos et al., 2010).
A paper in 2010 reported efficacy in gastric plication procedures,
as measured by changes in the weight progression of rats (Fusco et al.,
2010). Fusco et al. reported an increased effect from plication of the
greater curvature when compared to plication of the anterior surface.
Other clinical reports were done in 2009 and reported an increased weight
49
52
1.Balloon Measurements:
The gold standard for the measurement of tone in hollow organs
remains the barostat, which estimates changes in tone by the change of
volume of air in an infinitely compliant balloon maintained at a constant
pressure (Azpiroz and Malagelada, 1985). A variant is the tensostat,
which corrects, in real time, for the changes in volume or diameter of the
balloon to estimate luminal wall tension on the basis of the Laplace law
(Corsetti et al., 2004 & Distrutti et al., 1999).
One measurement of gastric capacity used a latex balloon, with a
capacity of ~1 liter attached to a double-lumen tube, passed orally into
the stomach. A pump, placed behind the subject, was used to fill the
balloon with water at a rate of 100 ml per min, with 1-min pauses to
record pressure, through a second lumen. The compliance of the balloon
in vitro was subtracted from the measured intragastric pressure. With
each 100 ml, abdominal discomfort was rated on a 0100 scale. The
53
result of gastric volume was based on the maximum tolerated volume and
the volume to produce a 5-cm water rise in intragastric pressure
(Geliebter et al., 2004).
Pitfalls in these forms of measurement include the need for
intubation and balloon distension under low constant pressure, which
may result in reflex relaxation of the stomach so that a true baseline
fasting volume cannot be estimated, and significant compliance of latex,
which necessitates correction each time the balloon is used since the
compliance may change with use as the latex is stretched by the water
within the balloon. The barostat measures a volume within a balloon
under constant pressure rather than true tone, volume, or tension in
absolute terms. These invasive tests are often unacceptable to patients
who are stressed and uncomfortable during these tests, which may last 3 h
or more. Given the practical limitations of balloon measurements of
gastric volume and accommodation, noninvasive volume-based methods
have been proposed to measure gastric capacity during fasting and
postprandially in the clinical setting and in research (Szarka and
Camilleri, 2009).
intravenous
administration
of
1020
mCi
[99mTc]
56
Figure 12
Diagram showing the technique of measurement of gastric emptying and
volume by SPECT (Simonian et al., 2004).
3. Ultrasonography:
Imaging-based volume methods include analysis of surface
geometry of human stomach by real-time, 3D ultrasonography or, most
recently, by 3D reconstruction of images acquired by ordinary
ultrasonography assisted by magnetic scan-head tracking (Gilja et al.,
1995) and (Liao et al., 2004). In the most recent application of
ultrasonography, an outline of the total stomach volume is visualized after
ingestion of a liquid meal that serves as a contrast medium. 3D
ultrasonography has been applied in adolescents and compared with
simultaneously measured gastric volumes by SPECT; further validation
and standardization are necessary (Manini et al., 2009).
57
4. CT Volumetry
Evolution:
CT was first used as a technique for measuring the volume of
internal organs by Heymsfield et al. in 1979 using a method known as
the summation-of-area method. The validity was examined in 4
waterfilled balloons, 12 excised human cadaver organs (6 kidneys, 3
livers and 3 spleens) and 2 human cadaver organs (4 kidneys, 1 livers and
2 spleens) remained in situ. The CT-derived volume of an organ slice
could be calculated by multiplying area and width as described later in
the 'Technique' section. By comparing the CT-derived volume and actual
volume (by water displacement), they found the difference within 3-5%
and confirmed the accuracy of this method.
Henderson et al. (1981) later applied this technique to measure
hepatic and splenic volumes in cirrhosis. The liver and spleen volume
was measured in 11 normal subjects and 12 cirrhosis patients. The results
achieved
were
compared
with
that
obtained
with
ultrasound
59
Figure 13
Basic principle of CT volumetry
Volume of single section = area x slice thickness
Overall volume = volumes in all relevant sections
61
LSG (group 1)
10
Number of cases
23
19
Lowest age
46
33
Highest age
31.6
26.7
Mean age
42.3
45.3
Lowest BMI
55.4
53.6
Highest BMI
49.46
49.83
Mean BMI
TABLE 1
62
Inclusion criteria:
All cases were chosen according to the following criteria:
BMI > 40 Kg/m2.
Age between 18 60 years.
No endocrinal causes for obesity.
Psychologically stable.
Sufficient non surgical trials to reduce weight.
Motivation & acceptance of surgical risks.
All patients were subjected to full clinical preoperative evaluation
as well as investigations.
Clinical evaluation aimed at assessment of degree of obesity,
preoperative evaluation and detection of different complications of
morbid obesity like hypertension, DM, sleep apnea, skeletal problems,
infertility, hernias, history of psychotherapyetc.
Investigations included :
Laboratory investigastions: CBC, FBS, renal functions, liver
functions, coagulation profile, lipid profile.
HORMONAL ASSAY to detect any endocrinal causes of obesity.
Pulmonary evaluation including X-ray chest & pulmonary
functions.
Cardiac assessment : ECG & Echocadiography if needed.
63
METHODS:
Surgical Technique:
Laparoscopic Sleeve Gastrectomy:
All procedures took place under general anaesthesia with the
patient lying in supine position. After induction of 15 mmHg
pneumoperitoneum, 5 trocars were inserted with sizes of 5, 10 and 12
mm. A window is dissected at the junction of the greater curvature and
the greater omentum, around 10 cm from the pylorus. Division of the
gastroepiploic, short gastric and posterior fundic vessels is done starting
at 4 cm proximal to the pyloric ring all the way till the angle of His using
the (ultracision Harmonic scalpel) (Harmonic; Ethicon Endosurgery,
Cincinnati, OH, USA) in all 10 cases. Once the dissection part is over, a
36 Fr bougie is introduced orally by the anaesthisiologist through the
oesophagus and inside the stomach. The surgeon then guides it along the
lesser curvature and into the pyloric channel and duodenal bulb.
Gastric transection begins 4 to 6 cm proximal to the pylorus. A 60mm, green or gold cartilage, is placed across the antrum through the right
midepigastric port and fired. The second stapler is placed approximately
1 to 2 cm from the border of the lesser curvature in the direction of the
GE junction. The bougie must be held in position during this part of the
procedure until completion of the stomach transection to avoid stapling
across a displaced bougie.
Sequential firings of the stapler along the border of the bougie on
the lesser curvature completes the gastric transection at the left crus. After
completing the transection, the entire staple line is inspected carefully to
make sure that the staples are well formed especially at the antrum where
64
Figure 14
Dissection of the greature curvature
65
Figure 15
Dissection of gastro-splenic ligament
Figure 16
Last step in greater curvature dissection
66
Figure 17
Firing the first stapler
Figure 18
Firing the last stapler
67
Figure 19
68
Follow-up of patients:
In the postoperative period, all patients were given 3rd generation
cephalosporins, anticoagulants, opioids, proton pump inhibitors and
antiemetics. Gastrographin meal was done to all patients in day 0. In day
one, all patients started oral fluids (if tolerated) after confirming that there
is no leakage in the study. All patients continued on oral fluids for one
month, followed by soft diet for another month and lastly on semisolids
for one more month. The drain was removed before discharging the
patients. All patients were discharged on day 2 after meeting the
discharge criteria of no bleeding, no leakage and no other complications.
All patients were followed up for one month on an outpatient basis.
CT volumetry were done to all patients at the end of the first
postoperative month.
CT Volumetry:
Patients Preparation:
Plain abdominal CT was performed on a Multislice CT 64-section
detector scanner (GE) (General Electric Medical Systems, Milwaukee,
WI, USA). All patients fasted for at least 8 hours before performing the
study. Before the CT examination, two packs of effervescent granules
were added to 10 ml of water and administered orally to each patient.
Patients were placed on the scanning table in the supine position. A scout
projection is then obtained showing the stomach fully distended by gas. If
the stomach is inadequately distended, one more pack is administered
orally to ensure adequate distension. A delay of 10 15 seconds was
needed to ensure complete distention of the stomach.
69
CT protocol:
Images were obtained from a level 12 cm below the dome of the
diaphragm to the lower pole of the right kidney during a single breath
hold. The helical CT data acquisition parameters were 120 kVp, 600 700 mA, 1.25 mm collimation, 5 mm reconstruction interval and rotation
time of 0.7 seconds. To complete imaging within the breath-hold period,
all image acquisition was completed within 30 to 40 seconds.
The 1.25-mm transverse CT sections were reconstructed at 0.5-mm
intervals, performed at a commercially available workstation (Advantage
Windows 3.1; GE Medical Systems). The contours of all stomach
sections were traced by means of a built-in cursor. During 3D
reconstruction for volumetry in LSG patients, the first section starts from
the most proximal radiodense staple till the pyloric ring. In case of LGP,
it starts roughly at the gastro-esophageal junction. The manufacturers
workstation with a specific software automatically calculated the number
of pixels included within the traced contours on each section and
provided the cross-sectional area of the stomach on a section-by-section
basis. The circumscribed areas were then automatically multiplied by the
CT section thickness, yielding an approximate volume for each stomach
section, and the volumes of all sections were summed to give the selected
stomach volume.
All data were statistically analyzed.
70
DISCUSSION
72
one month is not enough to assess the degree of gastric dilatation, if any,
that could occur after both procedures. More importantly, more time is
needed to investigate the amount of weight loss that both procedures
provide, which is the main parameter when it comes to assessing any
bariatric operation.
We would also like to shed light on the technique through which
the residual gastric volume has been assessed, CT volumetry, which has
proven its efficacy in evaluation of the volume of other organs, such as
the liver, but has not been widely used in assessing the stomach. More
research is needed in order to prove its accuracy with this particular
organ, which, if done, should provide a true evolution in the prediction of
the outcome of these two bariatric procedures and other restrictive
procedures as well.
75
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