Sleeve gastrectomy in the treatment of morbid obesity. Study results and first experiences with the transvaginal hybrid NOTES technique

BACKGROUND: Surgery for morbid obesity is also becoming more important in Germany. Besides standard procedures such as the Roux-en-Y (RNY) bypass, sleeve gastrectomy seems to be a new option which is mainly related to gastric restriction, neurohumoral changes and other unknown factors. The results of sleeve gastrectomy have to be compared with other established procedures such as the RNY bypass according the complication rate, weight loss and improvement of weight-related comorbidities such as diabetes and hypertension. PATIENTS AND METHODS: Between May 2008 and August 2009 sleeve gastrectomy was performed in a total of 200 patients (136 female and 64 male) with an obesity grade II-III. The average age of the patients was 43 years (range 21-72 years) and the average BMI 47.9 kg/m(2) (range 35.5-75.3 kg/m(2)). Of the patients 70 (35%) were diabetics and 96 (48%) suffered from hypertension. In 14 cases the operation was planned using the transvaginal assisted (hybrid NOTES) technique. RESULTS: Laparoscopic sleeve gastrectomy was possible in all patients. Of the patients 3 (1.5%) suffered from postoperative complications, such as leakage from the suture line in 2 (1%) cases and in 1 case (0.5%) with hemorrhaging from the abdominal wall and subsequent pulmonary embolism resulting in a mortality rate of 1% (2 cases). In the 197 cases without complications the mean hospital stay was 3.5 days (range 2-9 days). Using the transvaginal technique the number of trocars could be reduced by 1-2 and in all cases the resected stomach was retrieved transvaginally. No complications occurred due to the vaginal access. Antidiabetic medication was stopped 3 months after the operation in 45 (64%) out of 70 diabetics and the need for antihypertension drugs was also reduced. The mean weight loss after 3, 6 and 12 months was 27.3%, 41% and 58%, respectively. CONCLUSIONS: Sleeve gastrectomy seems to be an effective surgical option for the treatment of morbid obesity with a low complication rate. During the first year after the operation weight loss was excellent and weight-related comorbidities such as diabetes and hypertension improved significantly. The transvaginal hybrid NOTES technique can be performed but there is still need for additional trocars through the abdominal wall. Long-term results with respect to a durable weight loss and obesity-associated comorbidities are still lacking. The results of sleeve gastrectomy are at present comparable to those of a RNY bypass.