This lecture is about Sleeve Gastrectomy: A Surgical Revolution and Efficacy Insights. this transformative procedure has revolutionized the landscape of obesity treatment, offering hope and transformative results to millions of individuals struggling with excess weight and its associated comorbidities. Obesity has become a global epidemic, with profound implications for public health and individual well-being. According to the World Health Organization, more than 1.9 billion adults worldwide were overweight, and over 650 million were classified as obese in 2016. Obesity is associated with a host of life-threatening conditions, including diabetes, hypertension, cardiovascular disease, and even certain types of cancer.

Introducation:

Sleeve gastrectomy, initially developed as a restrictive component of the duodenal switch procedure, has gained substantial popularity as a standalone weight loss surgery in recent years. This minimally invasive procedure involves the removal of approximately 80% of the stomach, leaving behind a small, banana-shaped sleeve. It restricts food intake and has been associated with remarkable weight loss outcomes and improved metabolic health. In this lecture, we will delve into the origins and evolution of sleeve gastrectomy, explore its mechanisms of action, and discuss its efficacy, safety, and long-term outcomes.

Historical Perspective

To truly appreciate the significance of sleeve gastrectomy, we must first look back at its origins. The concept of surgically altering the stomach to facilitate weight loss dates back to the early 20th century, but it wasn't until the 1990s that sleeve gastrectomy emerged as a distinct procedure. It was initially employed as a component of the more complex duodenal switch surgery, primarily as a means of reducing the risk of malnutrition associated with the complete bypass of the duodenum.

However, over time, surgeons began to recognize the potential of sleeve gastrectomy as a standalone procedure due to its effectiveness in inducing weight loss and its relatively lower complication rates compared to other bariatric surgeries like gastric bypass. Consequently, it evolved into a primary option for weight loss surgery and quickly gained popularity worldwide.

Mechanisms of Action

Sleeve gastrectomy operates through a combination of restrictive and metabolic mechanisms. The reduction in stomach size restricts food intake, leading to decreased caloric consumption. Furthermore, the procedure removes the fundus of the stomach, which is a significant source of the hunger hormone ghrelin. This reduction in ghrelin levels helps suppress appetite, making it easier for patients to adhere to a reduced-calorie diet.

Moreover, the alteration in the anatomy of the stomach has been shown to have profound metabolic effects. Sleeve gastrectomy has been associated with improvements in insulin sensitivity, glucose metabolism, and hormonal regulation of appetite. These metabolic changes contribute significantly to the effectiveness of the surgery in treating obesity and related comorbidities, particularly type 2 diabetes.

Efficacy and Safety

One of the most compelling aspects of sleeve gastrectomy is its remarkable efficacy in promoting substantial and sustained weight loss. Numerous studies have demonstrated that patients can achieve an average excess weight loss of 60-70% within the first year following the procedure. This degree of weight loss not only leads to significant improvements in obesity-related health conditions but also enhances patients' overall quality of life.

Safety is a critical consideration in any surgical procedure, and sleeve gastrectomy has shown a favorable safety profile. The minimally invasive laparoscopic approach has reduced the risk of complications, such as infections and hernias. Short-term complications like leaks and bleeding are relatively rare, and advancements in surgical techniques have further improved patient outcomes.

Long-Term Outcomes and Challenges

While sleeve gastrectomy has proven to be highly effective in the short to medium term, long-term outcomes and challenges must also be acknowledged. Maintaining weight loss over several years can be challenging for some patients, and there is a potential for weight regain over time. This underscores the importance of ongoing follow-up and support, including dietary counseling and lifestyle modifications.

Additionally, the durability of metabolic improvements, particularly in the context of type 2 diabetes remission, remains an area of ongoing research and debate. While many patients experience significant improvements or even remission of diabetes following sleeve gastrectomy, long-term studies are needed to determine the extent to which these benefits persist.

How to perform surgery of Sleeve Gastrectomy by laparoscopy:

Performing a sleeve gastrectomy by laparoscopy, also known as laparoscopic sleeve gastrectomy (LSG), is a minimally invasive surgical procedure designed to help individuals with obesity lose weight effectively. This surgical technique has gained popularity due to its lower complication rates, shorter recovery times, and smaller incisions compared to traditional open surgery. Below, I will outline the steps involved in performing a sleeve gastrectomy using laparoscopy:

1. Preoperative Assessment and Patient Preparation:
   - Before the surgery, a thorough preoperative evaluation is essential. This includes assessing the patient's medical history, comorbidities, nutritional status, and psychological readiness for surgery.
   - Patients typically undergo extensive preoperative counseling and education to ensure they understand the procedure's risks, benefits, and long-term commitments.
   - Fasting guidelines are followed, and preoperative medications are administered as needed.

2. Anesthesia and Patient Positioning:
   - The patient is placed under general anesthesia to ensure they are unconscious and pain-free throughout the surgery.
   - The patient is positioned on the operating table, usually in a supine (lying on the back) position with arms extended.
   - The surgical team takes care to pad and position the patient securely to prevent pressure sores or injury during the procedure.

3. Creation of Pneumoperitoneum:
   - To facilitate laparoscopic access, the abdomen is inflated with carbon dioxide gas. This creates a pneumoperitoneum, which lifts the abdominal wall away from the internal organs and provides space for the laparoscopic instruments.
   - Typically, a Veress needle or a Hasson trocar is used to safely establish access to the abdominal cavity.

4. Trocar Placement:
   - Several small incisions (ports) are made in the abdominal wall. These incisions serve as entry points for the laparoscopic instruments and camera.
   - Typically, five to six ports are used during the procedure, with one serving as the camera port for visualization and the others for instruments.

5. Visualization and Dissection:
   - A laparoscope, a long, thin camera, is inserted through one of the ports to provide the surgical team with a visual guide inside the abdomen.
   - Dissection begins by separating the greater curvature of the stomach from its attachments to the surrounding tissues. This is usually done using a combination of energy devices, such as staplers and harmonic scalpel, to cut and seal the tissue simultaneously.
   - The dissection continues along the stomach's greater curvature until the entire stomach is dissected away from the abdominal wall.

6. Stapling and Resection:
   - Once the stomach is dissected, the next step involves stapling and resecting the stomach to create the sleeve shape.
   - Specialized surgical staplers are used to divide the stomach vertically, leaving behind a narrow, tubular structure known as the sleeve.
   - Care is taken to ensure proper alignment and sizing to prevent complications like leaks or strictures.

7. Reinforcement and Hemostasis:
   - After the stapling and resection, the staple line is often reinforced with additional sutures or staples to minimize the risk of leaks.
   - Hemostasis (control of bleeding) is carefully checked, and any bleeding points are addressed promptly.

8. Extraction and Closure:
   - The excised portion of the stomach is removed from the abdominal cavity through one of the port sites.
   - The remaining stomach sleeve is inspected to ensure there are no leaks or bleeding.
   - The ports are closed with sutures, and the skin incisions are typically closed with absorbable sutures or surgical glue.

9. Postoperative Care and Recovery:
   - Following the procedure, the patient is closely monitored in the recovery area before being transferred to the postoperative care unit.
   - Patients are gradually introduced to a clear liquid diet and are closely monitored for any postoperative complications.
   - Long-term follow-up with a multidisciplinary team, including dietitians, psychologists, and surgeons, is crucial to support patients in achieving their weight loss goals and maintaining their health.

Laparoscopic sleeve gastrectomy has become a gold standard in bariatric surgery due to its effectiveness and reduced invasiveness. Nevertheless, it is essential to note that the procedure carries risks and should only be performed by experienced bariatric surgeons in specialized centers. Patient selection, careful surgical technique, and ongoing postoperative support are essential components of a successful sleeve gastrectomy.

Advantage of Sleeve Gastrectomy surgery by laparoscopy:

Laparoscopic Sleeve Gastrectomy (LSG) is a minimally invasive surgical procedure that offers several advantages for individuals seeking effective weight loss and improved metabolic health. This surgical approach has gained popularity among both patients and healthcare providers due to its numerous benefits. Here are some of the key advantages of sleeve gastrectomy performed by laparoscopy:

1. Minimally Invasive Approach:
   - Laparoscopic sleeve gastrectomy is performed through small incisions, typically ranging from 5 to 6 small ports. This minimally invasive approach reduces trauma to the abdominal wall and muscles compared to traditional open surgery.
   - Smaller incisions result in less pain, reduced scarring, and a shorter recovery period for patients.

2. Lower Risk of Complications:
   - Laparoscopic procedures generally have a lower risk of surgical site infections and hernias compared to open surgery, which requires larger incisions.
   - The reduced risk of complications can lead to faster postoperative recovery and shorter hospital stays.

3. Improved Cosmesis:
   - Smaller incisions and less noticeable scars contribute to improved cosmetic outcomes, which are particularly important to many patients undergoing bariatric surgery.
   - Patients often appreciate the opportunity to achieve significant weight loss with less visible scarring.

4. Quicker Return to Normal Activities:
   - Patients who undergo laparoscopic sleeve gastrectomy typically experience a faster return to their daily activities and work.
   - This can have a positive impact on their overall quality of life and productivity.

5. Reduced Postoperative Pain:
   - Smaller incisions and less tissue manipulation during laparoscopic surgery result in less postoperative pain.
   - Reduced pain levels make it easier for patients to breathe deeply, move around, and engage in necessary postoperative activities, such as walking.

6. Shorter Hospital Stay:
   - Laparoscopic sleeve gastrectomy usually requires a shorter hospital stay compared to open surgery.
   - Many patients can be discharged within 1-2 days after the procedure, which lowers healthcare costs and allows patients to recover in the comfort of their homes.

7. Lower Risk of Wound Complications:
   - Laparoscopic incisions are smaller and less prone to infection or wound healing issues.
   - This reduces the risk of complications related to the surgical wounds.

8. Enhanced Visualization:
   - The laparoscope used in laparoscopic surgery provides surgeons with a high-definition, magnified view of the operative field.
   - This enhanced visualization allows for greater precision and accuracy during the procedure.

9. Lower Risk of Incisional Hernias:
   - Smaller incisions reduce the risk of incisional hernias, which can be a complication of open surgery.
   - Fewer incisional hernias mean fewer additional surgeries for patients.

10. Comparable Weight Loss and Metabolic Benefits:
    - Laparoscopic sleeve gastrectomy has been shown to achieve weight loss and metabolic improvements similar to those of open surgery.
    - It is as effective in terms of reducing excess weight and improving obesity-related comorbidities such as diabetes and hypertension.

Summary, laparoscopic sleeve gastrectomy offers numerous advantages, including reduced invasiveness, lower risk of complications, improved cosmetic outcomes, and quicker recovery times. These benefits have contributed to the widespread adoption of laparoscopic techniques in bariatric surgery, making it an attractive option for individuals seeking effective and sustainable weight loss and metabolic improvements. However, it is important to note that the choice of surgical approach should be made in consultation with a qualified bariatric surgeon, taking into account individual patient characteristics and preferences.

Conclusion:

Sleeve gastrectomy has indeed transformed the landscape of obesity treatment, offering a lifeline to those in need and paving the way for a healthier and more vibrant future for countless individuals around the world. Thank you for your attention, and I welcome any questions or discussions on this fascinating topic.

Sleeve gastrectomy represents a remarkable surgical revolution in the field of bariatric surgery. It has offered hope to individuals battling obesity and its associated comorbidities by providing an effective and safe means of achieving substantial and sustained weight loss. The procedure's multifaceted mechanisms of action, coupled with its relatively low complication rates, make it a compelling option for those seeking a long-term solution to obesity.

However, it is essential to recognize that sleeve gastrectomy is not a one-size-fits-all solution, and careful patient selection, comprehensive pre-operative evaluation, and ongoing post-operative support are paramount for success. Furthermore, continued research and long-term studies are essential to further elucidate the procedure's outcomes, particularly regarding metabolic improvements and weight maintenance.