Evaluation of water tolerance after laparoscopic sleeve gastrectomy

INTRODUCTION

Obesity is one of the most common life-threatening conditions. It is the new epidemic of the twenty-first century.1A comparison of data from 1988–90 with that from 2000–2002 shows that the prevalence of overweight (defined as body mass index, BMI, of 25–29.9 kg/m²) increased from 46% to 64.5%, and the prevalence of obesity (BMI ⩾ 30kg/m²) doubled to 30.5%.²

Obesity and overweight have many causes, including genetic, metabolic, behavioral and environmental causes. The rapid increase in prevalence suggests that behavioral and environmental influences predominate, rather than biological changes.³Obesity is associated with increased mortality and a high burden of comorbidities including diabetes mellitus, hypertension, non-alcoholic fatty liver disease, musculo-skeletal diseases, obstructive sleep apnea syndrome and certain types of cancers.^4.5

Several procedures are involved in the surgical management of morbid obesity as the field of bariatric surgery has grown remarkably over the past two decades with over 300,000 procedures performed annually and is now the second most common abdominal operation.⁶

According to the International Federation for the Surgery of Obesity and Metabolic Disorders, Laparoscopic sleeve gastrectomy (LSG) was the most commonly performed procedure worldwide in 2014 reaching 45.9% of all bariatric operations, after building on this experience that LSG was both safe and effective.⁷ Many surgeons proposed that LSG could be employed as a primary bariatric procedure.⁸

(LSG) has been demonstrated to be effective in weight loss and resolution of comorbidities.⁹ The percentage of excess weight loss after LSG reaches 60% to 75% in different studies.¹⁰ Laparoscopic sleeve gasterctomy (LSG) is one of the restrictive bariatric surgeries which often affects food and fluid tolerance and adversely affects the quality of life. Many studies assessed the tolerance of food and its different types but little number of studies assessed the fluid tolerance after LSG especially the water tolerance.¹¹

Fluid tolerance especially water is important for safe hospital discharge, weight loss and patient`s life style.¹²

In this study we aim to determine the effect of laparoscopic sleeve gastrectomy on water and juice tolerance with calculation of incidence and to compare this with short term outcome of LSG regarding excess weight loss and complications.

PATIENTS AND METHODS

This prospective study included 20 consecutive patients in Al-Azhar university hospitals who underwent LSG for morbid obesity from Dec 2020 to Jan 2022. The criteria of patients were identical to NIH 1991; patients having a BMI>40 kg/m, or patients having a BMI > 35 kg/m associated with co-morbidity (diabetes mellitus, hypertension, arthritis, or obstructive sleep apnea). We excluded patients younger than 18 years or older than 60 years. Patients with cardiac diseases, hypothyroidism, with history of dysphagia or odynophagia before the operation and who underwent previous upper GIT surgery or intragastric balloon, hiatus hernia surgery were excluded. Female patients who had conception during follow up and patients who suffer post-operative leakage or hemorrhage were also excluded.

All patients fulfilled the pre-operative questionnaire to exclude any dysphagia, heart burn, epigastric tenderness or hiccups after intake of water and different fluids. All candidates received prophylactic dose of anti-coagulant 12 h before surgery. Our candidates underwent general anesthesia, then placed in supine split leg position and the surgeon stands between the patient’s legs. A verse needle is then inserted and CO2 insufflation is induced until reaching 15mmHg then the patient is positioned in reverse Trendelenburg position. Five ports are placed and the liver retractor is inserted through the epigastric port to elevate the left live lobe. Dissection of the greater omentum from the stomach wall is started using ultrasonic dissector on the greater curvature of the stomach and it is continued carefully upward until reaching its end next to the left crus of the diaphragm, then the dissection is completed downward to 2-6 cm from the pylorus of the stomach. Once the greater curvature of the stomach is completely separated from the omentum, 36F bougie is inserted by the anesthetist to pass through the cardia, body and pylorus and it is pushed along the lesser curvature by the surgeon, then we use endoscopic stapler and start stapling the stomach from the pyloric part and continue stapling along the bougie as a calibration tube by using 3 to 4 linear staples with green or blue load until the cardiac end of the stomach. The sleeved stomach is inspected for any hemorrhage or leak after methylene blue test and the suture line hemostasis is established using endo-clips then the resected part of the stomach is removed through the camera port and a drain is inserted along the suture line for post-operative monitoring. The figures below demonstrate the mentioned steps.

Fig. 1: A: Elevating the liver with retractor and identifying the anterior surface of the stomach. B: Traction of the stomach to make a plane for dissection.

Fig. 2: A: A hole is made exposing the lesser sac of peritoneum. B: Perigastric dissection is conducted upward to the cadria.

Fig. 3: A: Upward dissection is almost complete reaching the left crus of the diaphragm. B: 36F bougie is passed through the pylorus along the lesser curvature.

Fig. 4: A: Resection of the stomach is started from the pyloric end 2-6 cm from the pylorus in upward direction using linear staplers. B: After firing the 1st staple dividing the sleeved stomach on the right and the resected stomach on the left.

Fig. 5: A: The last stapler is fired to complete the resection cautiously to prevent any injury of adjacent structures e.g. spleen. B: Complete separation was done and the suture line of the sleeve is inspected for hemorrhage or leak.

Post-operative assessment

Patients took oral questionnaire  to assess their tolerance to liquids 48hrs and 3 months post-operatively and upon their answers, they were categorized into 4 groups: Group A; Early water intolerant, Group B;  Delayed water intolerant, Group C; early juice intolerant and Group D; delayed juice intolerant.

Radio-opaque multi-series meal x-rays were taken twice, the first post- operative DI or D2 and the other one 3 months post-operative, In both series, patients were asked to drink 50 cc of water as well as sugar-free juice, both mixed with 20 ml of radio-opaque contrast.

Water and juice were followed radiologically till passage to the duodenum. Esophageal and gastric transit time were assessed and categorized for both water and juice as "Immediate passage" in which fluid passes smoothly from the esophagus to the stomach (esophageal transit) or from the stomach to the duodenum (gastric transit) without a notable delay (less than 10 sec), (Delay) in which fluid flow shows some delay in the passage process with no more than 20 s and (Hold-up) in which there is more than 20 s delay before any notable passage. The figures below show examples for CS tests.

Fig. 103: Gastrograffin meal with juice D2 post-operative slow (hold up) gastric transit = (contrast reaches the duodenum after 39 sec from passing the LES).

Collected subjective tolerance data were compared and correlated with flow pattern of the CS. Percent excess weight loss (%EWL) and complications were also assessed after 3 months. Patients who were intolerable to water after 3 months underwent upper GI endoscopy for possible complications assessment.

RESULTS

Table 1: Description of demographic data in all studied patients.

This table shows the description of demographic data in all studied patients. As regard age, the mean age of all studied patients was 30.9 ± 7.1 years with minimum age of 18 years and maximum age of 44 years. As regard weight, the mean weight of all studied patients was 116.9 ± 17.9 kg with minimum weight of 92.5 kg and maximum weight of 166 kg. As regard height, the mean height of all studied patients was 1.59 ± 0.06 m with minimum height of 1.5 m and maximum height of 1.75 m. As regard BMI, the mean BMI of all studied patients was 45.9 ± 6.6 kg/m2 with minimum BMI of 38.9 kg/m2 and maximum BMI of 64.8 kg/m2. As regard sex, there were 3 males (15%) and 17 females (85%) in the studied patients. There were 11 patients (55%) with positive co-morbidities in the studied patients.

Patients were categorized into 4 groups Group A (early water intolerant) included 10 patients (50%) of the sample, group B (delayed water intolerant) included 6 patients (30%), group C (early juice intolerant) included 3 patients (15%) and group D (delayed juice intolerant) was only 1 case (5%).

The number of water intolerant patient decrease after 3 months, decreasing from 10 patients (50%) to only 6 patients (30%) after 3 months, but it is notable that 2 patients of those 6 were tolerant to water at early period

.

Fig. 11: Black circle: early water intolerant, red circle: early water tolerant, blue circle: delayed water intolerant.

Group B (delayed water intolerant group) underwent upper GI endoscopy to asses any organic cause for delayed water intolerance, the results showed unremarkable findings in 5 of those patients with only one case showing stenotic sleeve segment. 2 (10%) patients of group C (early juice intolerant) improved 3 months later and became tolerant to juice and the third (5%) patient remain intolerant to juice. The mean %EWL (excess weight loss) among early water tolerant patients was 33.6% while it was 30.55% among early water intolerant on the 3-month follow up.

Early contrast study for water and juice flow patterns in the esophagus showed that 14 of 20 patients (70%) had immediate esophageal transit for water and it was 15 (75%)for juice esophageal transit. 4 patients had delayed esophageal transit (10-20 sec) for water while only 3(15%) patients had delayed juice esophageal transit. The early esophageal transit for water was hold up (more than 20 sec) in 2 (10%) patients and it was the same for early esophageal transit for juices.

After 3 months, contrast study for water and juice flow pattern in the esophagus showed that 15 of 20 (75%) patients recorded immediate esophageal passage of water (compared to 14 in the early study) and the other 5 patients (25%) had delayed esophageal transit for water with no incidence of hold up. And for juice contrast study, 17 of 20 (85%) had immediate esophageal transit (compared to 15 on the earlier study) while the other 3 patients (15%) had delayed esophageal transit with no incidence of a hold up

Regarding the early gastric contrast study of the water,  8 patients (40%) were of immediate passage,  7 (35%) were with delayed gastric transit and the other 5 (25%) had a hold up,  after repeating to the juice in the early period,  6 patients (30%) had immediate transit of juice through the stomach while 7 patients (35%) had delayed passage and the other 7 patients (35%) had a hold-up.

Delayed contrast study of the stomach after 90 day showed more retardation in the gastric transit of both water and juice,  as only 2 patients (10%) had immediate passage of water, 10 patients (50%) had delayed transit and 8 (40%) recorded a hold-up. On the other hand juice gastric transit was immediate in only 1 patient (5%) and delayed in 7 patients (35%) and 12 patients (60%) recorded a hold-up for juice gastric transit.

Table 2: Comparison between (water and juice) at day 2 as regard tolerability, esophageal CS and gastric CS.  X2: Chi-square test.  S: p-value < 0.05 is considered significant.                 NS: p-value > 0.05 is considered non-significant.

This table shows: statistically significant (p-value<0.05) increased percentage of tolerability to juice (17 patients, 85%) at day 2 when compared with tolerability to water (10 patients, 50%). No statistical significant difference (p-value>0.05) between water and juice as regard esophageal CS and gastric CS at Day 2.

Table 3: Comparison between (day 2 and day 90) as regard tolerability, esophageal CS and gastric CS.  X2: Chi-square test.            NS: p-value > 0.05 is considered non-significant.

This table shows no statistical significant difference (p-value > 0.05) between (day 2 and day 90) as regard tolerability, esophageal CS and gastric CS.

Table 4: Comparison between (water and juice) at day 90 as regard tolerability. 

X2: Chi-square test.                S: p-value < 0.05 is considered significant.

This table shows statistically significant (p-value < 0.05) increased percentage of tolerability to juice (19 patients, 95%) at day 90 when compared with tolerability to water (14 patients, 70%).

Table 5: Comparison between (day 2 and day 90) as regard weight.

T: independent sample T test.         S: p-value < 0.05 is considered significant.

This table shows statistically significant (p-value = 0.001) decreased weight at day 90 (99.8 ± 12.9 kg) when compared with weight at day 2 (116.9 ± 17.9 kg).