Laparoscopic Sleeve Gastrectomy, 529 Cases
Without a Leak: Short-Term Results
and Technical Considerations
Drake Eric Bellanger & Frank L. Greenway
# Springer Science+Business Media, LLC 2010
Background Laparoscopic sleeve gastrectomy (LSG) is
gaining acceptance among bariatric surgeons as a viable
option for treating morbidly obese patients. We describe
results of a single surgeon’s experience with LSG in a
community practice revealing a low complication rate and
describing the surgical technique.
Methods LSG was performed in 529 consecutive patients
from December 2006 to March 2010. A technique is
described where all operations were performed with
attention to avoiding strictures at the incisura angularis
and stapling close to the esophagus at the angle of His. No
operations performed used buttressing material or over-
sewing of the staple line. A retrospective chart review and
e-mail survey was conducted to determine the occurrence
of complications and weight loss.
Results Follow-up data was collected on 490 of the 529
(92.6%) patients at6 weeks.A total complicationrateof3.2%
and a 1.7% 30-day readmission rate were observed. No leaks
occurred in any of the 529 patients, and one death (0.19%)
was observed. The most common complications were nausea
and vomiting with dehydration and venous thrombosis. The
percentages of excess weight loss were 42.36, 65.92, 66.11,
and 64.42 with a follow-up of 71%, 68%, 63%, and 49% at
6 months, 1 year, 2, and 3 years, respectively.
Conclusion The LSG can be performed in a community
practice with a low complication rate. Surgeons performing
LSG should strive to minimize the risk of creating strictures
at the incisura angularis and stapling near the esophagus at
the angle of His.
Keywords Sleeve gastrectomy.Gastric leak.
Morbid obesity has become a major health problem in the
United States . Laparoscopic sleeve gastrectomy (LSG)
has shown promise as an operation that can be done with a
reduced rate of complications . LSG was first performed
as a stage procedure for high-risk individuals undergoing
staged bypass procedures , and recently, LSG is showing
more promise as a primary procedure to treat morbid
obesity [4, 5]; however, for any bariatric procedure to be
widely adopted, the procedure must be performed with
minimal complications .
This paper will attempt to illustrate a single surgeon’s
experience in 529 consecutive laparoscopic sleeve gastrec-
tomy operations in a community practice, performing the
procedures in a 90-bed suburban hospital. Technical consid-
erations that we feel can decrease the risk of staple line leak
will be discussed. Additionally, the paper will examine the
incidence of complications of this emerging procedure.
All patients entering our practice requesting bariatric
surgery were offered three procedure options: laparoscopic
gastric bypass, adjustable gastric banding, and LSG. After a
one-on-one consultation with the surgeon, the patients
made an informed decision to have LSG and informed
D. E. Bellanger (*)
St. Elizabeth Hospital,
1014 West St. Clare, Suite 1000,
Gonzales, LA 70737, USA
F. L. Greenway
Pennington Biomedical Research Foundation,
6400 Perkins Road,
Baton Rouge, LA 70808, USA
consent was obtained. All patients were required to have
psychological screening, routine labs, electrocardiogram,
upper gastrointestinal X-rays, pulmonary function studies,
and a medical evaluation. All patients were scheduled for
LSG as a primary definitive procedure.
All patients received intravenous antibiotics, subcutaneous
unfractionated heparin and sequential compression devices
The abdomen is entered under direct vision with an
OptiView (Ethicon Endo-Surgery, Cincinnati, OH) trocar.
Three 5-mm, one 12-mm, and one 15-mm ports are placed
as pictured (Fig. 1). A liver retractor is used to support the
liver. The pylorus is identified, and an area approximately 3
to 4 cm from the pylorus is chosen to begin ligating and
transecting the greater curvature vessels with a Harmonic
Scalpel (Ethicon Endo-Surgery, Cincinnati, OH). The
greater curvature of the stomach is mobilized to the angle
of His, with particular attention paid to mobilizing the
entire fundus to the mid-portion of the left crura of the
diaphragm. A 34-French bougie is passed by anesthesia and
positioned in the distal antrum. Resectioning of the antrum
is started tangentially from the right lateral port using a
green load (4.1 mm), positioning the tip of the stapler to
give a distance of one and a half times the width of a
bougie at the area of the incisura angularis (Fig. 2). All
stapling is performed using the Echelon 60 Endopath
(Ethicon Endo-Surgery, Cincinnati, OH) stapler, holding
initial compression for a minimum of 15 and 5 s of
compression between strokes of the device. Resectioning of
the body and fundus of the stomach is achieved using blue
loads (3.5 mm) via the 15-mm left mid-clavicular port site
to the angle of His. We intentionally do not mobilize the
periesophageal fat pad in order to visually position the
stapler to leave approximately 1 cm of gastric tissue lateral
to the angle of His (Fig. 3). It is our practice not to use
buttress material or over-sew the staple line, but our routine
practice is to wait and allow adequate compression with the
stapling device. Fibrin glue is applied to the staple line and
the 15-mm port site is closed with absorbable suture.
and receive heparin as prophylaxis for deep vein thrombosis
and are ambulated the night of the surgery. Patients are given
water and ice the day of the surgery and a clear liquid diet on
postoperative day number one. Patients are discharged
postoperative day number one as tolerated and are routinely
placed on a daily proton pump inhibitor for 1 month.
Fig. 1 Standard trocar placement
Fig. 2 First application of stapler one and a half times the distance
from the 34-French bougie
Fig. 3 Application of stapler lateral to periesophageal fat pad
The charts of 529 consecutive patients beginning December
2006 through March 2010 who had undergone LSG in our
practice were evaluated retrospectively. The patient’s
weight, body mass index (BMI), age, and gender are
summarized (Table 1). Sixty-three of the 529 patients
(12%) were categorized as super obese (BMI≥55).
Follow-up data was obtained on 490 of 529 (92.6%)
patients at 6 weeks. The total complication rate was 3.2%
with 1.7% readmission within 30 days of surgery. Mortality
was 0.19% out of the 529 patients. That one patient died
from a suspected pulmonary embolus at home, 9 days after
the operation. There were no leaks in 529 consecutive
sleeve gastrectomy patients. The most common complica-
tions were vomiting with dehydration and venous throm-
bosis (five each) with other complications being less
common (Table 2). Weight loss data was collected by a
combination of office measurement and self-reported weight
via e-mail and telephony. Data was collected on 81 of 166
(49%) at 3 years, on 206 of 328 (63%) at 2 years, on 294 of
434 (68%) at 1 year, and on 377 of 529 (71%) patients at
6 months. Percent excess weight loss was chosen to track
successful weight loss for the procedure. Patients lost
64.42%, 66.11%, 65.92%, and 42.36% excess weight at
3 years, 2 years, 1 year, and 6 months, respectively (Fig. 4).
weight loss as the first stage of a two-staged bypass procedure
. More recently, LSG is showing promise as a primary
bariatric procedure for appropriate candidates [4–6]. Cur-
rently, LSG comprises only 2% of all bariatric operations in
the United States .
As a two-stage procedure, the initial reports of LSG were
performed witha 60-French bougie and were reported tohave
a 33% excess weight loss (percent EWL) at 11 months .
From there, surgeons began using LSG as a primary bariatric
procedure using smaller-sized bougies with reported greater
percent excess weight loss (62% EWL) . In a systematic
review by Brethauer et al. , weight loss ranged from 33%
to 85% of excess weight in patients having LSG. Wiener et al.
 have demonstrated the durability of LSG at 5 years.
Some reports have shown that decreasing the size of the
bougie can lead to a greater percent excess weight loss ,
although some have disputed a cause and effect relationship
between weight loss and bougie size in the short-term .
In addition, there is continued disagreement as to whether
LSG represents a strictly restrictive procedure versus a
combination restrictive/hormonal procedure . Studies
have shown the effects of LSG on ghrelin levels and hunger
, as well as additional metabolic hormones .
As LSG becomes adopted by more bariatric surgeons,
there becomes a need for the procedure to become
standardized to achieve similar results across different
practices and must be considered safe by the public .
Additionally, Wiener et al. noted that LSG is not a simple
procedure, and owing to the fact that the procedure is
irreversible, surgeons should strive to avoid complications
. In Louisiana, very few insurance plans have coverage
for any form of bariatric surgery; therefore many patients
must finance their own procedures. The current system in
Louisiana also allows the patient to directly choose the
procedure that they feel will balance their concern for
surgical side effects with their personal desires and expect-
Table 2 Complications in 529 sleeve gastrectomy patients
Vomiting and dehydration
Mesenteric venous thrombosis
Deep venous thrombosis
Severe reflux esophagitis
Pulmonary embolism (death)
Fig. 4 Percent excess weight loss
Table 1 Demographics of the 529 sleeve gastrectomy patients
Preoperative body mass index
ations for a weight loss operation. Minimizing the chance
of complications is a major consideration, and we feel our
technique has achieved this for our patients.
Technically, when performing LSG we use the harmonic
scalpel to ligate and transect the greater curvature vasculature
andshort gastric vessels. We avoid thermal injury to anytissue
that will be subsequently involved in the staple line by placing
the active blade anterior and angling the blade away from
gastric tissue. Devices using bipolar electrocautery can also be
and when used properly, either device should not increase the
incidence of staple line dehiscence.
We advocate the use of a 34-French bougie without the
use of buttressing material or over-sewing of the staple line.
Our philosophy is to begin 3 to 4 cm from the pylorus
thereby decreasing the antral volume while preserving its
function. We feel we are able to minimize the chance of
stricture formation and proximal staple line failure by
allowing an effective 50-French diameter at the incisura
to this area. Esophagogastroscopy and saline submersion was
employed as a leak test for the first 350 patients, and no leaks
were detected. No intraoperative leak test is currently
employed; however, all staple lines are carefully inspected at
the time of the operation. We do not, as a routine, leave a
drain; however, we may leave a drain for complex cases or
procedures with greater than the average blood loss.
The incidence of staple line dehiscence after LSG ranges
from 0% to 5.5% [2, 14–17] and with overall complication
rates ranging from 0% to 24% . Lalor et al.  have
advocated over-sewing the staple line to minimize staple line
dehiscence while others routinely use only buttress material
 or both . Additionally, some technique studies have
advocated avoiding the incorporation of the area of the
gastroesophageal junction into the staple line [14, 15]. Our
results of 0% leak rate in the 529 cases compares favorably
the use of staple line protective maneuvers. We firmly believe
there are two main tenets to adopt in order to minimize leaks.
First, and of utmost importance, is to avoid creating a
physiologic stricture at the incisura angularis and second,
avoid stapling too close to the esophagus in the area of the
cardia. We also advocate time for compression of the gastric
tissue with the stapling device, thus promoting proper staple
formation and reducing both serosal trauma and bleeding.
Leaks after LSG can result in significant morbidity .
There is also a tendency for leaks after LSG to occur in a
latent fashion and appears to be associated with an increase
pressure in the sleeved stomach and/or improper staple
formation . Regarding pressure, Gagner et al. have
noted an inverse relationship between bougie size and leak
rate and advocates a bougie size between 50 and 60 French to
minimize this complication . Mery et al. describe the
relationship between staple height and the pressure required
to produce staple line failure in a bench study using porcine
small bowel . Using this model, staple line failure was
experienced at 50.4 mmHg for white loads (2.5 mm),
59.8 mmHg for blue loads (3.5 mm), and 18.7 mmHg for
green loads (4.1 mm) when the staplers were used without
buttress material . The obvious limits of this study as it
applies to LSG is the use of an animal model and much
thinner small bowel, although one may be able to argue that
the white and blue staple loads would perform similar to the
blue and green loads in gastric tissue. Yehoshua et al. have
described what is probably the most ideal technique to
determine sleeve volume and pressure relationship to date
and determined the basal sleeve pressure to be 19 mmHg and
the filled pressure to be 43 mmHg . Therefore, using all
the information previously presented, a properly performed
LSG should avoid creating a high-pressure situation within
the sleeve lumen (<55 mmHg) and should be executed with
appropriately sized staples for the tissue being coapted.
We have not performed pressure–volume measurements
on our patients after LSG; however, we feel that our
technique minimizes pressure in the sleeve as advocated by
Gagner (50 French at the incisura angularis) while
providing for complete resection of the fundus (34 French
for body and fundus). Likewise, staple cartridge selection
for our technique (green for antrum, blue for body and
fundus) has resulted in a clinically low incidence of staple
line failure. Which of these two factors, if any, is most
important, would be of interest for further study.
Laparoscopic sleeve gastrectomy has shown promise as a
primary bariatric procedure and as a staged procedure for
high-risk patients. Our data reveal that the procedure can be
performed in a community practice with a low complication
rate and adequate medium-term weight loss. Additionally,
surgeons performing LSG should strive to minimize the
risk of creating strictures at the incisura angularis and
stapling near the esophagus at the angle of His. We concede
that the major weaknesses of our study include the marginal
follow-up rates, the self-reported weight data, and the lack
of primary pressure–volume measurements.
Conflict of Interest Disclosure
honoraria from Ethicon Endo-Surgery. Dr. Greenway is a consultant or
board member for Basic Research, Dow Chemical, General Nutrition
Corporation, GlaxoSmithKline, Jenny Craig, Leptos Biomedical,
Lithera Inc., NuMe Health LLC, Obecure Ltd., Oncometa Pharma-
ceutical, Orexigen Therapeutics, Third Rock Ventures, and Schering-
Plough. Dr. Greenway also receives honoraria from Carolinas Medical
and PlenSat Inc.
Dr. Bellanger receives teaching
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