Results of laparoscopic sleeve
gastrectomy: A prospective study
in 135 patients with morbid obesity
David Fuks, MD, Pierre Verhaeghe, MD, Olivier Brehant, MD, Charles Sabbagh, MD,
Frederic Dumont, MD, Michel Riboulot, MD, Richard Delcenserie, MD, and
Jean-Marc Regimbeau, MD, PhD, Amiens, France
Background. Sleeve gastrectomy is a new restrictive bariatric procedure increasingly indicated in the
treatment of morbid obesity. The authors report their experience of laparoscopic sleeve gastrectomy (LSG),
evaluate the efficacy of this procedure on weight loss, and analyze the short-term outcome.
Methods. The data of 135 consecutive patients undergoing LSG between July 2004 and October 2007
were analyzed prospectively. LSG was indicated only for weight reduction with a body mass index (BMI)
> 40 or > 35 kg/m2associated with severe comorbidity. Study endpoints included mean BMI, comor-
bidity, operative data, conversion to laparotomy, intraoperative complications, major and minor com-
plication rates, excess weight loss, follow-up, and duration of hospital stay. Possible risk factors for
postoperative gastric fistula (PGF) were investigated.
Results. This series comprised 113 females and 22 males with a mean age of 40 years (range, 18--65).
Mean weight was 132 kg (range, 94--186), and mean preoperative BMI was 48.8 kg/m2(range, 37–
72). The mean operating time was 103 minutes (range, 30–550). No patients required conversion to
laparotomy, and 96% of patients did not require drainage. The nasogastric tube was removed on
postoperative day 1. The postoperative course was uneventful in 94.9% of cases, and the median du-
ration of hospital stay was 3.8 days. The median follow-up was 12.7 months. The mean postoperative
BMI decreased to 39.8 kg/m2at 6 months (P < .001). Average excess body weight loss was 38.6% and
49.4% at 6 months and 1 year, respectively. There was no mortality, and the major complication rate,
corresponding to gastric fistula (PGF) in every case, was 5.1% (n = 7). Management of PGF required
reoperation, radiologic and endoscopic procedures, and fibrin glue; the median hospital stay was 47
days. BMI > 60 kg/m2appears to be a risk factor for PGF.
Conclusion. LSG is a reproducible and seems to be an effective treatment to achieve significant weight
loss after 12 months follow-up. LSG can be used as a standalone operation to obtain weight reduction.
Management of PGF remains a major issue. (Surgery 2009;145:106-13.)
From the Federation of Digestive Diseases, Amiens North Hospital, University of Picardy, Amiens, France
THE GROWING PREVALENCE OF MORBID OBESITY and the
(body mass index [BMI] > 50 kg/m2) seeking sur-
gical treatment has led to the development of sur-
gical techniques designed to provide adequate
excess weight loss (EWL) with the least possible
morbidity. A recent study has emphasized that
weight loss also allows improvement of life expec-
are laparoscopic adjustable gastric band (LAGB)
and laparoscopic gastric bypass (LGB). Laparo-
scopic sleeve gastrectomy (LSG), a restrictive oper-
ation, consists of vertical gastrectomy including the
entire greater curvature of the stomach. Although
LSG is associated with a greater morbidity than
LAGB, it avoids some of the disadvantages of
LGB such as excessive restriction of intake, margi-
nal ulceration, and dumping syndrome.2-5We re-
port our experience with LSG, evaluating the
safety and efficacy of this procedure as a stand-
Patient selection. All obese patients seen at
Amiens North Hospital were entered into a pro-
spective database specifically devoted to bariatric
procedures. The database was initiated in 2004 and
Accepted for publication July 7, 2008.
Reprint requests: Jean-Marc Regimbeau, MD, PhD, Department
of Digestive Surgery, Amiens North Hospital, University of Pic-
ardy, Place Victor Pauchet, F-80054 Amiens Cedex 01, France.
0039-6060/$ - see front matter
? 2009 Mosby, Inc. All rights reserved.
is maintained prospectively. The data for 135
consecutive patients undergoing LSG between
July 2004 and October 2007 were analyzed pro-
spectively. LSG was indicated for weight reduction
only for patients with a BMI > 40 or > 35 kg/m2
with severe comorbidity. All patients were offered
2 other bariatric procedures (LAGB or LGB), but
LSG was decided in all cases. All patients were as-
sessed by a dietician, a nutritionist, and a psychol-
ogist before surgery. This study was performed with
the approval of our hospital’s institutional review
board. During the study interval, 120 patients un-
derwent LAGB, and 12 patients underwent LGB.
Data collected included patient demographic
data, past medical history, comorbidities, weight
and BMI, operative data (operating time, compli-
cations, conversion, drainage), duration of stay,
morbidity/mortality rates, and follow-up.
Operative procedures and postoperative man-
agement. All operations were performed laparos-
copically under general anesthesia using the
French position (legs abducted with the surgeon
standing between the patient’s legs). Each proce-
dure required only 4 trocars. Two 12-mm ports
were placed in the supraumbilical region and in
the left upper quadrant. One 5-mm port was
placed in the right upper quadrant for liver
retraction. One 15-mm port used for stapling was
placed in the left mid-abdomen, just medial to the
mid-clavicular line (Fig 1).
Pneumoperitoneum was induced by primary
trocar insertion and maintained at a pressure of
16 mm Hg. Dissection began on the greater cur-
vature, 6 cm from the pylorus. The gastrocolic
ligament along the greater curvature of the stom-
ach was opened using an impedance coagulator
(Ligasure; Tyco, Mansfield, Mass) and was freed as
far as the cardioesophageal junction at the root of
the left pillar of the hiatus. The short gastric vessels
close to the spleen were carefully coagulated sep-
arately. A 34-F plastic tube was then inserted
perorally into the stomach by the anesthesiologist
and was directed toward the pylorus. A laparo-
scopic linear stapler (EndoGIA; Tyco) was intro-
duced intothe peritoneal
positioned so that it divided the stomach parallel
to the orogastric tube along the lesser curvature.
The instrument was fired, reloaded, and the
maneuver was repeated; 2 sequential 4.8/60-mm
green cartridges were used to staple the antrum
followed by 3 or 4 sequential 6.5/60-mm blue
cartridges to staple the remaining gastric corpus
and fundus. The diameter of the gastric tube was
therefore 34 F. After 5 or 6 firings of the stapler,
the greater curvature was completely detached
from the stomach and placed in a 15-mm retrieval
bag. A methylene blue test (150 ml of methylene
blue fluid was introduced by a nasogastric tube
while a forceps constricted the pylorus) was per-
formed to exclude staple-line leakage. The gastric
suture line was not systematically reinforced except
in the case of bleeding or positive methylene blue
test, in which case a drain was placed along the
staple line. A nasogastric tube was left in place.
A water-soluble upper gastrointestinal (GI) con-
trast study using methylglucamine diatrizoate was
performed on the first postoperative day, and oral
fluids were allowed if no leakage was demon-
strated. Patients were discharged except in the
case of a complication resulting in prolongation of
the hospital stay.
Definitions. Patients were reviewed at 1 month
and then every 3 months. Complications and
reoperations were recorded for all patients. Mor-
tality and morbidity were defined as death or
complications and reoperations during the first
30 days after the operation or during the hospital
stay, respectively. Complications were graded ac-
cording to the Clavien classification system6: grade
I, a complication inducing any deviation from the
normal postoperative course; grade II, complica-
tions requiring pharmacologic treatment; grade
III, complications requiring operative, endoscopic,
or radiologic intervention; grade IV, life-threaten-
ing complications requiring intermediate or inten-
sive care unit management; and grade V, death of a
Statistical analysis. Univariate analysis included
the Chi-square test or the Fisher exact test for
qualitative variables or the Student t test for quan-
titative variables, as appropriate. The Mann-Whit-
ney U test was used for nonparametric variables.
A P value of .05 or less was considered statistically
significant in univariate analysis.
Fig 1. Placement of 4 trocars. Two 12-mm ports were
placed in the supraumbilical region and in the left up-
per quadrant. One 5-mm port was placed in the right-up-
per quadrant for liver retraction. One 15-mm port used
for stapling was placed in the left mid-abdomen just me-
dial to the mid-clavicular line.
Volume 145, Number 1
Fuks et al 107
Preoperative results. A total of 135 consecutive
patients (113 females and 22 males) with a mean
age of 40 years (range, 18--65) underwent LSG
between July 2004 and October 2007. Mean pre-
operative weight was 132 kg (range, 94--186) and
mean preoperative BMI was 48.8 kg/m2(range,
37–72) (Table I). Median history of obesity was
17 ± 7 years. Fifty-three patients (44%), among
the 135, had hypertension; 45 (33%) had dyslipi-
demia; 38 (28%) had obstructive sleep apnea;
and 33 (24%) had type 2 diabetes mellitus. LSG
was performed as the primary procedure in 131 pa-
tients and as redo bariatric surgery in 4 patients af-
ter failure of LAGB.
Intraoperative results. The mean operating time
was 103 minutes (range, 30--550), and none of the
patients required conversion. Of the 135 patients,
intraoperative bleeding occurred in 10 (7%) and
required polypropylene suture. No spleen injury
occurred during laparoscopy, and none of the
patients required transfusion. The staple line
failed in 3 patients (positive methylene blue test),
and a running polypropylene suture was necessary.
In 13 patients, a minor injury of the left lobe of the
liver occurred but did not require any specific
treatment. No drainage was performed in 96% of
patients. The learning curve was approximately 30
Postoperative course. There was no mortality in
this series, and the postoperative course was un-
eventful in 94.9% of cases. The nasogastric tube
was removed on postoperative day 1. The median
duration of hospital stay was 3.8 days for patients
without postoperative complications, and 2 days
for the last 50 patients included in the study.
The major postoperative complication rate (gas-
tric fistula in every case) was 5.1% (n = 7). The de-
tails of these 7 patients are shown in Table II.
Postoperative complications occurred even after
more than 100 procedures. Two patients with
PGF developed postoperative pneumonia (Clavien
grade II) (Table III). PGF was detected on the first
postoperative day by water-soluble upper GI con-
trast study in 4 (57%) of the 7 patients. For the
other 3 patients, PGF was diagnosed later by com-
puted tomography (CT) scan (intraabdominal ab-
scess). The median time to diagnosis of PGF was
4.8 days (range, 1–52). PGF was located in front
of the spleen on the upper part of the staple line
(angle of His) in every case (Fig 2). Of the 7 pa-
tients with PGF, 6 (85%) required reoperation
with laparotomy (Clavien grade IIIb). All patients
with simple suture of the PGF required a second-
stage procedure because of failure. In each patient,
the operative procedure consisted of drainage with
intubation of the leakage. Intraoperative gastros-
copy was necessary in 5 patients to locate the leak-
age; this procedure was performed by introduction
of a hydrophilic guidewire due to the large volume
of fatty tissues in obese patients as well as inflamma-
tory changes in the surrounding tissues with local
Jejunostomy was performed in 2 patients to
allow postoperative enteral nutrition. Of the 7
patients with PGF, 4 (57%) required additional
percutaneous drainage for an intraabdominal col-
lection. After draining intraabdominal fluid col-
lections or abscesses, 3 patients were treated by
endoscopic stent placement with glue injection.
Fibrin glue was used during the first procedures,
but the PGF persisted and histoacryl glue was
found to be more effective. The stent was removed
endoscopically after 4 weeks. One patient devel-
oped postoperative gastrobronchial fistula, which
was treated by multiple radiologic and endoscopic
procedures (3 stents, histoacryl glue). All 7 pa-
tients received antibiotics, parenteral nutrition,
and somatostatin analogs. No bleeding from the
staple line or trocar wound was observed. The
median duration of hospital stay was 47 days
(range, 17--94) in patients with PGF.
Risk factors for gastric fistula. Risk factors for
PGF after LSG were analyzed in this series of 135
patients. On univariate analysis, comorbidities (ob-
structive sleep apnea, hypertension, dyslipidemia,
type 2 diabetes mellitus) were not found to be risk
factors for PGF, nor were age (P = .17), sex
(P =.78), or LAGB failure (P = .48). Preoperative
BMI was a risk factor for PGF (P = .009); the me-
dian BMI of patients with PGF was 55.3 vs 48.3
kg/m2in patients without PGF. A preoperative
BMI > 60 kg/m2was identified as a risk factor for
PGF (P = .0002). Only 1 of the 3 patients with sta-
ple-line failure developed PGF.
Long-term follow-up: Evaluation of weight loss.
The median follow-up was 12.7 months. The me-
dian decrease of BMI after 6 months was 9 kg/m2
(range, 48.8–39.8; P < .001). Average excess body
weight loss was 38.6% and 49.4% at 6 months
Table I. Preoperative body mass index (BMI)
108 Fuks et al
and 1 year, respectively. Preliminary EWL at 2 years
was 56%. No patient developed malnutrition. In
terms of late complications, 2 patients presented
an insufficient weight loss treated by a second-stage
operation (laparoscopic duodenal switch). Among
patients who had LSG after failure of LAGB, 1 had
PGF. Of the 4 patients who underwent LSG after
failure of LAGB, 3 had significant weight loss
(EWL, 35%) after 12 months follow-up. Only 1 pa-
tient required further operation (duodenal switch)
because of failure of LSG. No patients required
gastric dilatation after LSG.
This study shows that LSG is an effective and
reproducible procedure in bariatric surgery with a
EWL of 38.6% and 49.4% at 6 months and 1 year,
respectively, after a median follow-up of 12.7
no patients required conversion to laparotomy, and
no mortality, and the postoperative course was
uneventful in 94.9% of cases. The median duration
of hospitalstay was3.8 daysand 2 days for the last50
patients in the series. The major complication rate,
comprising gastric fistula (PGF) in every case, was
Management of PGF remains a major issue
(reintervention, radiologic and endoscopic proce-
dures, fibrin glue, and median hospital stay of 47
days). A BMI > 60 kg/m2appears to be a risk factor
A total of 16 reports have been published in the
peer-reviewed literature describing short-term out-
comes in more than 800 patients after LSG for
obesity (BMI ranging from 35 to 69 kg/m2).7-11In
the various series, EWL ranged from 33% to 83%.
Only a single prospective randomized trial9com-
pared LSG to LAGB and provided data for up to
3 years. In this trial,9the median decrease of BMI
was 15.5 kg/m2for LAGB and 25 kg/m2for LSG
after 1 year (P < .0001) and 18 kg/m2for LAGB
and 27.5 kg/m2for LSG after 3 years (P = .0004).
The median EWL was 41.4% after LAGB and
57.7% after LSG at 1 year (P = .0004) and 48% after
LAGB and 66% after LSG at 3 years (P =.0025).9
Weight regain or a desire for further weight loss
in a super-super-obese patient may require revision
of the procedure to LGB or duodenal switch. In our
study, 2 patients underwent laparoscopic duodenal
switch due to insufficient weight loss. For 1 patient,
LSG was performed because of LAGB failure.
The seducing potential of LSG relies in the
fact that this operation, unlike LAGB, is a
straightforward procedure that can be generally
completed laparoscopically even in the case of an
extremely obese patient.12In addition, LSG does
not involve any digestive anastomosis; no mesen-
teric defects are created eliminating the risk of in-
ternal hernia13; no foreign material is used as with
LAGB; the entire digestive tract remains accessible
to endoscopy (for further treatment of potential
gastric cancer); it is not associated with dumping
syndrome; the risk of peptic ulcer is low; and the
absorption of nutrients, vitamins, minerals, and
drugs is not altered. LAGB is not associated with
a decline of the circulating levels of ghrelin,14
and Karamanakos et al15showed a higher ghrelin
level reduction after LSG than after LGB in
a prospective, double-blind study. In addition, res-
hypertension, hyperlipidemia, and sleep apnea,
has been reported in many patients 12 to 24
months after LSG.8,16-18These results are compara-
ble to those of other restrictive procedures. Long-
term data (>5 years) for weight loss and comorbid-
ity resolution have not yet been reported for LSG.
It has been suggested that the size of the gastric
tube is a factor influencing the degree of weight
loss. This may be partly explained by complete
resection of the gastric fundus, which contains
most of the ghrelin-producing cells.4,19No consen-
sus, however, has been reached regarding the opti-
mal dilator size that should be used to create the
lesser curve conduit, with various reports recom-
mending diameters between 32 and 60 F. The de-
gree of weight loss in our series was similar to
that reported by Mognol et al11(EWL of 41% at
6 months) who used the same size of gastric tube
(34 F), but it was lower than the results reported
by Himpens et al.9
The 2 most common operative complications
after bariatric operations are staple-line bleeding
and anastomotic leakages.11These complications
can be life-threatening or even fatal.20-25Published
complication rates range from 0% to 24%, with an
overall reported mortality rate of 0.39%. The post-
operative staple-line bleeding rate was 7.3% in the
studyby Silecchiaetal.18Inarecent study reporting
the complications after 148 one-stage LSG,26the
PGF rate was low (0.7%, n = 1), but 1 case of postop-
erative abscess was probably related to missed PGF.
In our study, major postoperative complications
(PGF in every case) occurred in 5.1% of patients,
operative complications of anastomosis after distal
gastrectomy for cancer.27The incidence of suture
pling and 0% to 29% for hand suturing.27
Volume 145, Number 1
Fuks et al 109
PGF mainly occurred on the first 7 postopera-
tive days (‘‘early’’ PGF) or after postoperative day 7
(‘‘delayed’’ PGF). In our study, 5 (71.4%) patients
had ‘‘early’’ PGF, which was mainly (80%) diag-
nosed by water-soluble upper GI contrast study.
Two patients had ‘‘delayed’’ PGF, diagnosed by CT
and a second water-soluble upper GI contrast
study. These results highlight the role of CT in
cases of sepsis even many days after surgery. All
intraabdominal fluid collections on CT after LSG
should be considered to be PGF and to require
aggressive management. In the recent study by
Serra et al,28the authors reported 6 cases of PGF
after bariatric surgery, all occurring during the first
7 postoperative days. Among them, 2 of 125
(1.6%) occurred after LSG. More recently, a multi-
center study focusing on LSG reported a 3.66%
rate of PGF,29which is similar to the rate observed
in our study. Recently, PGF after LSG is increas-
ingly described in the literature.
Since we submitted this paper, we have per-
formed 52 additional LSG without occurrences of
PGF; our current rate of PGF is 3.7%. During the
study interval, because of postoperative fistulas, we
modified the reinforcement of the staple line
using buttress material in several patients. How-
ever, 1 more gastric fistula occurred, and we
stopped to systematically reinforce the staple line.
It is difficult to recommed not reinforcing the
staple line, given the rate of postoperative gastric
fistula in our series. More recently, because PGF
was always located on the upper part of the staple
line, we thought fistula formation was secondary to
the tension of the last staple line. We therefore
modified the procedure during the study interval.
Initially, we particularly pulled on the stomach to
apply the last staple line near the nasogastric
tube. Changing the left trocar position, we tried
to pull lesser on the stomach to allow a tensionless
application of the last staple line. We have not yet
analyzed the impact of this technical modification
on the occurrence of PGF.
Operative treatment is the mainstay for patients
with signs of sepsis and/or hemodynamic instabil-
ity.30-33Six (85%) patients required reoperation
due to clinical and laboratory signs of sepsis; peri-
tonitis was detected on laparotomy in 5 of these pa-
tients. Operative procedures are a subject of
controversy, but all patients with PGF treated with
primary suture in our series required a second op-
eration with intubation of the PGF and adequate
drainage. We therefore do not recommend pri-
mary suture in PGF. However, a preoperative meth-
ylene blue test was positive in 3 patients, and only
1 required reoperation. Precise localization of the
leakage was difficult during reoperation due to the
large amount of fatty tissue in obese patients and
inflammatory changes in the surrounding tissues
due to local peritonitis. Intraoperative gastroscopy
is recommended to identify the site of leakage by
introducing a hydrophilic guidewire. This proce-
dure was successful in all cases and can help intu-
bate the leakage.
Table II. Details of postoperative gastric fistula (PGF)
SexAge (y)BMI Methylene blue test
Water-soluble upper GI
F, Female; M, male; BMI, body mass index; GI, gastrointestinal; CT, computed tomography; POD, postoperative day; Positive, visualized the PGF; Negative,
did not visualize the PGF; F, fibrin glue; H, histoacryl glue; R, recovery (oral feeding without symptoms for >1 month); O, ongoing.
Table III. Postoperative complications (Clavien
Grade/type of complicationNo. of patients
Delayed gastric emptying
Central venous catheter infection
110 Fuks et al
Patients with minimal clinical signs or patients
who develop ‘‘delayed’’ PGF may be managed con-
servatively with percutaneous drainage, total paren-
teral nutrition, or distal enteral feeding and
antibiotics. Most patients with leakage should be
immediately returned to the operating room to
avoid overwhelming sepsis. Conservative manage-
ment is only appropriate in very carefully selected
instances. Only 1 of the 7 patients with PGF in our
series was managed conservatively. Enteral feeding
must be initiated early, because adequate nutrition
is important to ensure leakage closure.27A feeding
jejunostomy was performed in 3 patients. A feeding
jejunostomy can be used instead of total parenteral
nutrition to provide the patient with nutrition
until the fistula closes. This approach is purely
Time to diagnosis No. reoperationsOperative procedureStent (no.) Glue (type)Follow-up (m)Status
2 (POD 1–14)
1 (POD 1)
2 (POD 1–7)
1 (POD 4)
2 (POD 7–13)
1 (POD 15)
Suture/intubation + drainage
Intubation + drainage
Suture/intubation + drainage
Intubation + drainage
Intubation + drainage/drainage
Intubation + drainage
Table II. (continued)
Fig 2. Postoperative gastric fistula. (A) Coronal reformatted abdominal enhanced computed tomography (CT) 15 days
after operation shows a pneumoperitoneum located in the angle of His (arrow) outside of the staple line. (B) Axial cur-
vilinear abdominal enhanced CT 15 days after operation shows a gastric leak (arrow) with contrast medium extravasation
in the angle of His. (C) Diagram of laparoscopic sleeve gastrectomy shows the site of a postoperative gastric fistula. (D)
Abdominal plain radiograph shows the stent location (black arrow) with percutaneous drainage.
Volume 145, Number 1
Fuks et al 111
speculative; no data are available on its use. and this
issue has not been addressed in the literature.
The use of fibrin glue applied endoscopically to
3 patients required multiple procedures with fibrin
of intraabdominal fluid collections or abscesses. Fi-
brin glue was used during the first procedures of
this series but was ineffective; histoacryl glue was
found tobe more effective.Stent placement isanal-
ternative treatment option for PGF, because it can
temporarily bypass the site of leakage at the gastroe-
sophageal junction and allow maintenance of en-
teral nutrition until complete closure of the
our series.Almostallauthors havereportedthatthe
optimal time for removal of the stent is approxi-
mately 6 to 8 weeks.28,30,34,36The optimal timing
of stent removal, however, was 4 weeks in this series
due to the appearance of gastric mucosal lesions
when the stent was removed later.
super-obesity has been found to be a risk factor for
PGF after LSG. The multidisciplinary management
of PGF is long and difficult. PGF was successfully
closed after 8 months of follow-up in only 4 pa-
tients, whereas the other 3 patients required mul-
hospital stay was 47 days in patients with PGF.
In conclusion, LSG is reproducible and seems
to be an effective treatment to achieve significant
weight loss after 12 months follow-up. LSG can be
used as a standalone operation to obtain weight
reduction. Safety and efficacy of this procedure
should be confirmed by further evaluation. In our
achieved satisfactory weight loss at short-term fol-
low-up, with minor complications and no mortal-
ity. PGF is a serious complication that requires
interventional procedures. In our study, BMI > 60
kg/m2was a risk factor for PGF. Further studies are
required to determine the long-term efficacy of
LSG in terms of weight loss.
The authors thank Miss Crepin for help with this work.
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