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A Review of Laparoscopic Sleeve Gastrectomy

for Morbid Obesity
ARTICLE in OBESITY SURGERY APRIL 2010
Impact Factor: 3.74 DOI: 10.1007/s11695-010-0145-8 Source: PubMed

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University of Alberta

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OBES SURG
DOI 10.1007/s11695-010-0145-8

REVIEW

A Review of Laparoscopic Sleeve Gastrectomy

for Morbid Obesity
Xinzhe Shi & Shahzeer Karmali & Arya M. Sharma &
Daniel W. Birch

# Springer Science+Business Media, LLC 2010

Abstract Laparoscopic sleeve gastrectomy (LSG) is an

innovative approach to the surgical management of morbid
obesity. Weight loss may be achieved by restrictive and
endocrine mechanisms. Early data suggest LSG is efficacious in the management of morbid obesity and may have
an important role either as a staged or definitive procedure.
A systematic review of the literature analyzing the clinical
and operational outcomes of LSG was completed to further
define the status of LSG as an emerging treatment modality
for morbid obesity. Data from LSG were compared to
benchmark clinical data and local operational data from
laparoscopic adjustable gastric band (LAGB) and laparoscopic gastric bypass (LRYGB). Fifteen studies (940
patients) were identified following systematic review. The
percent excessive weight loss (%EWL) for LSG varied
from 33% to 90% and appeared to be sustained up to
3 years. The mortality rate was 0-3.3% and major
complications ranged from 0% to 29% (average 12.1%).
Operative time ranged from 49 to 143 min (average
100.4 min). Hospital stay varied from 1.9 to 8 days
(average 4.4 days). The operational impact of LSG has
not been described in the literature. According to data from
the Royal Alexandra Hospital, the estimated total cost of
LSG was $10,317 CAD as compared to LAGB ($7,536
CAD) and LRYGB ($11,666 CAD). These costs did not
X. Shi (*) : D. W. Birch
Centre for the Advancement of Minimally Invasive Surgery
(CAMIS), Royal Alexandra Hospital,
10240 Kingsway Ave. CSC Rm 508,
Edmonton AB T5H 3V9, Canada
e-mail: xinzhe.shi@albertahealthservices.ca
S. Karmali : A. M. Sharma
University of Alberta,
Alberta, Canada

include further surgical interventions which may be

required for an undefined group of patients after LSG.
Early, non-randomized data suggest that LSG is efficacious
in the surgical management of morbid obesity. However, it
is not clear if weight loss following LSG is sustainable in
the long term and therefore it is not possible to determine
what percent of patients may require further revisional
surgery following LSG. The operational impact of LSG as a
staged or definitive procedure is poorly defined and must
be analyzed further in order to establish its overall health
care costs and operational impact. Although LSG is a
promising treatment option for patients with morbid
obesity, its role remains undefined and it should be
considered an investigational procedure that may require
revision in a subset of patients.
Keywords Laparoscopic . Sleeve gastrectomy . Morbid .
Obesity

Introduction
Obesity is a worldwide epidemic. Recent data show an
increased prevalence of obesity in the adult and pediatric
populations [1]. Globally, there are more than 1 billion
overweight adults, at least 300 million of them obese [1].
The 2004 Canadian Community Health Survey: Nutrition
documented 23.1% of Canadians aged 18 or older
(approximately 5.5 million adults) with a body mass index
(BMI) of 30 kg/m2 or more. Using the World Health
Organization classification of obesity [2], it has been shown
that individuals in each obesity class are at increased risk of
obesity-related illness as compared to those with a normal
BMI (18.5-24.9) [3, 4]. Remarkably, cancer is the leading

OBES SURG

cause of mortality in obese patients. Obesity accounted for

as much as one in seven cancer deaths in men and one in
five in women in the USA [57].
For patients with morbid obesity (obesity class II or III),
surgical management remains the only evidence-based
approach to achieving clinically important and sustainable
weight loss [8]. In 1991, a National Institutes of Health
Consensus Conference developed recommendations regarding the surgical management of obesity and established the
current indications for surgery [9].
A minimally invasive approach to the surgical management of obesity has been shown to dramatically reduce
perioperative morbidity through reduced blood loss, hospital stay, and wound complications [10]. Laparoscopic rouxen-Y gastric bypass (LRYGB) and laparoscopic adjustable
gastric banding (LAGB) have become the most frequently
performed bariatric procedures in the USA [11].
Laparoscopic sleeve gastrectomy (LSG) has recently
been identified as an innovative approach to the surgical
management of obesity. In this procedure, the greater
curvature of the stomach is resected producing a narrow,
tubular stomach with the size and shape of a banana
(Fig. 1). This procedure has quickly attracted considerable
surgical interest because it does not require a gastrointestinal anastomosis or intestinal bypass and it is considered
less technically challenging than LRYGB. LSG also avoids
implantation of an artificial device around the stomach in
comparison to LAGB [12]. Weight loss following LSG is
achieved by both restriction and hormonal modulation.
Firstly, reduction in stomach size with the sleeve resection
restricts distention and increases the patients sensation of
fullness (decreasing meal portion size). This restriction is
further facilitated by the natural band effect of the intact
pylorus which is maintained during the sleeve gastrectomy.
Secondly, early evidence suggests a reduction in the hunger

drive of patients undergoing sleeve gastrectomy. This may

be related to decreasing serum levels of ghrelin, a hormone
produced mainly by P/D1 cells lining the fundus of the
human stomach which stimulates hunger [13].
LSG may be offered to patients as a definitive procedure
for morbid obesity or as the first step in a staged surgical
approach for patients with very high BMI (>60 kg/m2). In
the staged approach, following initial weight loss induced
by LSG, surgical management may be completed by
revising the LSG to a gastric bypass or a biliopancreatic
diversion with a duodenal switch (Fig. 2). If a patient
requires a secondary procedure following LSG (either
planned or due to weight regain), analysis of clinical
outcomes or operational impact (costs to healthcare system)
of LSG should be cumulated and consider both procedures.
In this study, we analyzed the clinical outcomes and
operational impact of LSG in a systematic review of the
literature. Our aim was to understand if the best available
evidence supports the use of LSG as a definitive procedure
for morbid obesity and to determine the operational costs
and resource impacts for LSG in a definitive or staged
approach to morbid obesity.

Fig. 1 Sleeve gastrectomy

Fig. 2 Quality assessment of studies

Methods
A systematic review of the literature was performed for LSG.
We searched for published or unpublished studies of LSG
written in English prior to April 2009. The search strategy was
applied to several electronic bibliographic databases including
Medline (Pubmed search engine), Embase, Cochrane library,
International Network of Agencies for Health Technology
Assessment using the following key words: laparoscopic,
endoscopic, minimally invasive surgery, LSG, vertical gastrectomy, partial gastrectomy, longitudinal gastrectomy, morbid obesity, obese, and overweight. Conference abstracts were
also searched including Society of American Gastrointestinal
Endoscopic Surgeons and American Society for Metabolic
and Bariatric Surgery between 2000 and 2009.
Inclusion criteria for searches were: randomized controlled trials, non-randomized clinical trials, retrospective
and prospective cohort studies, or case series. Studies were

OBES SURG

included if they involved patients diagnosed with morbid

obesity (BMI>40) or BMI between 35 and 40 with severe
co-morbidities and underwent LSG. Studies were excluded
if LSG was used for treatment of diseases other than
morbid obesity, if investigators provided only surgical
technique outcomes, or if follow-up was not reported.
Fifteen studies [1428] were selected for review using
the above search strategy. One study was one randomized
control trials (study quality: grade B, level of evidence: 2b);
six studies were retrospective and eight studies were
prospective studies (grade C, level of evidence: 4) either
with or without control groups.
A formal meta-analysis was not conducted in this review
because of the high degree of heterogeneity among these
studies. Eleven of 15 studies did not have a control group
for comparison and the remaining five studies had different
surgery procedures as comparing groups: three of them
compared LSG with LAGB at 6 months, 2 years, and
3 years follow-up; the final two compared LSG with
intragastric balloon and duodenal switch. Thus, it is not
appropriate to undertake a statistical analysis based on the
available evidence. Only descriptions of mean, range, and
percentage were summarized and discussed in the review.

Results
We assessed the quality of these 15 selected studies; there
were only one RCT with moderate risk bias and the
remainder were controlled or case series studies with high
risk of bias (Fig. 2).
We summarized data from 15 published studies (940
patients) describing short-term outcomes following LSG (see
Appendix 1). These results were summarized in Table 1 and
compared to the best available evidence for LRYGB and
LAGB [29, 30]. One study was available that provided

Table 1 Summary of clinical outcomes of LSG as compared to

LRYGB and LAGB
Outcomes

LAGB

LRYGB

Number of cases
Operative time (min)
Hospital stay (days)
%EWL (1 year)
%EWL (2 year)
%EWL (3 year)
Comorbidity resolution
Complications
Mortality

3,374
77.5
1.7
37.8%
45.0%
55.0%
41-59%
6.50%
0.47%

3,195
164.8
4.2
62.8%
54.4%
66.0%
65-84%
9.50%
0.56%

LAGB and LRYGB references: [29, 30]

LSG
940
100.4
4.4
59.8%
64.7%
66.0%
45-95.5%
12.1%
0.3%

follow-up data up to 3 years; the remainder have a follow-up

from 6 months to 2 years. Preoperative BMI ranged from 37.2
to 69 kg/m2 and 28.8% of patients were male. Operative time
ranged from 49 to 143 min with an average time of
100.4 min. Hospital stays were from 1.9 to 8 days, on
average 4.4 days. The percent excessive weight loss (%EWL)
ranged from 33% to 90% with follow-up from 6 months to
36 months. Comorbidity resolution 12-24 months after LSG
had been reported in 365 patients (see Appendix 2). The data
demonstrated rates of resolution and improvement of diabetes, hypertension, hyperlipidemia, degenerative joint disease,
gastroesophageal reflux, peripheral edema, sleep apnea, and
depression after LSG ranging from 45% to 95.3% and
comparable to results of other restrictive procedures. One
randomized trial was published which compared LSG to
LAGB; results showed LSG at least as effective and durable
as gastric banding at 1 and 3 years following surgery [21].
As with other procedures for bariatric surgery, perioperative risk for LSG appeared to be relatively low even in
patients considered high risk. The overall reported
mortality rate for LSG was 0.3%. Published complication
rates ranged from 0% to 29% (average 11.2%). Some
studies reported all minor complications (vomiting, nausea,
and diarrhea) and others did not, confounding analysis.
Major complications, such as staple line leakage and
internal bleeding were summarized in Table 2.

Costs
We were unable to identify published literature on the
economic evaluation of LSG alone or in contrast to the
Table 2 Major peri-operation complications of LSG
Studies

Leakage

Arias 2009
Nocca 2008
Lee 2007

0.7%
5.5%
1.4%

Melissas 2007
Cottame 2006
Himpens 2006
Langer 2006
Roa 2006
Silecchia 2006
Baltasar 2005
Han 2005
Milone 2005
Mogno 2005
Almogy 2004
Regan 2003
MeanSD

5.3%
1.6%
0
0
2.4%
0
0
0.7%
0
0
0
0
1.17%1.86%

Hemorrhage
0
0.6%
0
15.8%
0
2.5%
0
3.3%
4.9%
6.5%
0.7%
5%
0
0
14.3%
3.57%5.15%

OBES SURG

LAGB or LRYGB. Given the important variation in

techniques for bariatric surgery and varying use of
endomechanical devices which greatly influence cost, we
have reviewed the operational costs for LSG, LAGB, and
LRYGB at our institution in order to understand the
operational impact to healthcare. We identified 27 typical
cases of LAGB, LRYGB, and LSG from three bariatric
surgeons patients for costing estimation. Data were
obtained from the Royal Alexandra Hospital, Alberta
Health Services and Alberta Medical Association. Mean
operating times were used as a basis for determining human
resource costs (i.e., assistant and anesthetist). Surgeon
charges to Alberta Health and Wellness were referenced.
For operating room costs, important features of the surgical
techniques were included: disposable trocars used in all
cases, ultrasonic dissection (harmonic scalpel) was used for
dissection in LRYGB and LSG, the Swedish Adjustable
Gastric Band was used for LAGB, the Orvil technique
was used for the RYGB, Peristrips dry and Tisseel were
used in the majority of LSG cases. Major device and
endomechanical costs were itemized in Table 3.
An estimate of the overall costs of LSG when used
in a staged surgical approach for high-risk or high BMI
patients would include the total costs of LSG and a
secondary procedure (i.e., for LRYGB as the secondary
procedure total costs would be $10,142 + $11,477 =
$21,619).

Discussion
If current trends in the prevalence of obesity persist by
2010, 27% of Canadian men and 24% of Canadian women

Table 3 Operational costs of

LSG vs. LRYGB and LAGB

LAGB (n=9)
Anesthesia

Costs were based on mean operative time: 43 min LAGB,

135 min LRYGB, 110 min LSG;
LOS: 1.1 day LAGB, 2.9 day
LRYGB, 2.7 day LSG (Royal
Alexandra Hospital, June 2008June 2009)

will be obese [31]. In 2004, one in four (26%) Canadian

children and adolescents aged 217 years were overweight.
The obesity rate has increased dramatically in the last
15 years: from 2% to 10% among boys and from 2% to 9%
among girls [32]. The total direct healthcare cost of obesity
in 2001 was estimated to be over $1.6 billion, which
corresponded to 2.2% of the total health care expenditures
for all diseases in Canada [33]. Bariatric surgery is the only
evidence-based approach to sustainable weight loss and by
improving comorbid disease and survival, healthcare costs
after bariatric surgery (RYGB) are recovered in approximately 3 years.
LSG is an innovative procedure for the management
of obesity. It was originally developed as a first-stage
bariatric procedure to reduce surgical risk in high-risk
patients through the induction of dramatic weight loss.
Analysis of the literature suggests LSG is efficacious in
the short term and may offer certain advantages when
compared to the existing options of LAGB and LRYGB.
These advantages include: technical efficiency, lack of an
intestinal anastomosis, normal intestinal absorption, no
risk of internal hernias, no implantation of a foreign
body, pylorus preservation (prevents dumping syndrome),
and finally LSG may be considered the most appropriate
option in extremely obese patients [22]. Moreover, the
entire upper gastrointestinal tract remains accessible for
endoscopic assessment. Concerns remain however, regarding the risks and important major complications
associated with LSG including staple line leak (1.17%),
post-operative hemorrhage (3.57%), and the irreversibility
of LSG.
With respect to the evidence on the various technical
aspects of performing LSG, there is currently no consensus

Assistant
Surgeon
Endomechanicals:
Trocars
Staplers
Ultrasonic Dissector
Peristrips
Tisseel
SAGB
Orvil Stapler
All other
Hospitalization ($485/day)
Total

LRYGB (n=9)

LSG (n=9)

$204

$641

$523

$589
$1,032

$605
$2,615

$432
$1,075

$323
$4,500
$354
$534
$7,536

$335
$2,998
$713
$967
$1,385
$1,407
$11,666

$316
$2,021
$713
$2,525
$749
$654
$1,310
$10,317

OBES SURG

and standardization of the technique. Specifically, regarding

bougie size, there may be a trend towards a smaller caliber
sleeve. Between 2003 and 2006, bougie sizes ranged from
32 to 60 Fr, while from 2007 to 2009 sizes varied only from
32 to 40 Fr. The evidence suggests a smaller bougie size
may result in greater weight loss and may prevent later
stretch of the sleeve. The operational impact and total
healthcare costs for LSG are poorly defined. Our analysis
suggests that LSG may be costly, especially in a staged
surgical approach to obesity. Further, as a staged procedure,
LSG will require experienced bariatric surgeons with
advanced laparoscopic skills to complete the second stage
procedure safely and efficiently. The overall time to recoup
costs for LSG as compared to LRYGB has not been
determined and warrants further analysis.
Medium-term clinical outcomes for LSG will emerge in
the very near future, however, long-term (>10 years) weight
loss and co-morbidity resolution data for LSG will remain
undefined for several years. Weight regain or a desire for
further weight loss in a super-obese patient may require

revision to a gastric bypass or biliopancreatic diversion.

Surgeons and patients considering LSG should be fully
informed of the limitations of current data.

Conclusion
Early, non-randomized data suggest that LSG is efficacious
in the surgical management of morbid obesity. It is not clear
if weight loss following LSG is sustainable in the long
term. Until such outcomes are obtained from high quality
studies, the role of LSG in the surgical management of
obesity remains undefined and it should remain as an
investigational procedure. The operational impacts of LSG
as a staged or definitive procedure are poorly defined and
must be analyzed further.

Conflict of interest disclosure

no conflict of interest.

The authors declare that they have

Appendix 1

Table 4 Summary of included studies

Author

Year Country Design

Patient Male Age

no.

LOS

OR
time
(min)

Pre
Follow-up Post
%EWL
operative (year)
operative
BMI
BMI

Arias
[14]

2009 USA

Retrospective 130

36

45.6

3.2

97

43.2

Nocca
[15]

2008 France

Prospective

163

52

41.6

45.9

Lee
[17]
Melissas
[16]
Cottam
[22]
Himpens
[21]

2007 USA

Retrospective 216

43

44.7

1.9

49

27.7

2007 Greece

Prospective

38.9

47.2

31.1

2006 USA

Retrospective 126

59

49.5

65.3

49

2006 Belgium RCT

40

40

39

Langer
[20]
Roa
[19]
Silecchia
[18]
Baltasar [26]

2006 Austria

Prospective

23

41.2

48.5

1.5

2006 Korea

Retrospective 30

40

3.2

80

41.2

0.5

32

2006 Italy

Prospective

41

13

44.6

5.7

111

57.3

40.8

2005 Spain

Prospective

7
7

49

6174
>40

27 months
16 months

Han
[23]

3543

27 months

2005 Korea

Retrospective 60

37.2

23

16
8

30

66

143

27.1

Complication Bougie Mortality

(Fr)

67.9%
9.8%
(62.2%
1 year)
61.5%
7.4%
(59.5%
1 year)
59%
6%

46%

40

36

32

21.7%

34

14%

46
50
34

0
0

48

13%

60

12%

48

6.70%

32

3.3%

48

1.7%

66%
5%
(57.7%
1 year)
56%
4%
53%

56.1%
33.6
90%
62.3%
28

83.3%

OBES SURG
Table 4 (continued)
Author

Year Country Design

Milone
[25]
Mogno
[24]
Almogy
[27]
Regan
[28]
Mean
SD
Range

2005 USA

Retrospective 20

13

2005 France

Prospective

10

43

7.2

2004 USA

Retrospective 21

44

2003 USA

Retrospective 7

43

2.7

Patient Male Age

no.

940a

LOS

OR
time
(min)

Pre
Follow-up Post
%EWL
operative (year)
operative
BMI
BMI

Complication Bougie Mortality

(Fr)

114

69

0.5

53

35%

5%

60

120

64

41

51%

32

57.5

1.5

61%

23.8%

63

11 months 50

33%

29%

60

12.1%
8.1%
029%

43.7
10.9
32
03.3%
60

124

271a 42
4.4 100.4 52
4.6
2.3
30
10.6
30
1.98 49
37.2
49.5
143
69

1.40.7
0.53

27.153

33
90%

0
0

Total number

Appendix 2
Table 5 The improvements of comorbidities after LSG
Cottam (2006) [22]

Han (2005) [23]

Milone (2005) [25]

Silecchia (2006) [18]

Average R+I

Patients
Follow-up
Type 2 diabetes

126
1 year
81%R
11%I

60
1 year
100%R

20
6 months
30%I

41
18 months
79.6%R
15.4%I

247
624 months
77.2%

Hypertension

78%R
7%I
73%R
5%I
80%R
7%I
85%R
6%I
70%R
8%I
91%R
3%I
67%R
9%I

93%R
7%I
45%R
30%I
100%R

55%I

62.5%R
25%I

71.7%

76%R
24%I
80%R
20%I

Hyperlipidemia
Sleep apnea
Degenerative
Joint disease
Gastro- esophageal
Reflux
Peripheral Edema
Depression

30%I
60%I

61%

95%I

56.2%R
31.2%I

83.6%
95.3%

25%I

67.7%

94%

14%I

45%

R resolved; I improved

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