title: Laparoscopic sleeve gastrectomy as an initial weight-loss procedure for high-risk patients with morbid obesity.
abstract: BACKGROUND
  The surgical treatment of obesity in the high-risk, high-body-mass-index (BMI) (>60) patient remains a challenge. Major morbidity and mortality in these patients can approach 38% and 6%, respectively. In an effort to achieve more favorable outcomes, we have employed a two-stage approach to such high-risk patients. This study evaluates our initial outcomes with this technique.
  
  
  METHODS
  In this study, patients underwent laparoscopic sleeve gastrectomy (LSG) as a first stage during the period January 2002-February 2004. After achieving significant weight loss and reduction in co-morbidities, these patients then proceeded with the second stage, laparoscopic Roux-en-Y gastric bypass (LRYGBP).
  
  
  RESULTS
  During this time, 126 patients underwent LSG (53% female). The mean age was 49.5 +/- 0.9 years, and the mean BMI was 65.3 +/- 0.8 (range 45-91). Operative risk assessment determined that 42% were American Society of Anesthesiologists physical status score (ASA) III and 52% were ASA IV. The mean number of co-morbid conditions per patient was 9.3 +/- 0.3 with a median of 10 (range 3-17). There was one distant mortality and the incidence of major complications was 13%. Mean excess weight after LSG at 1 year was 46%. Thirty-six patients with a mean BMI of 49.1 +/- 1.3 (excess weight loss, EWL, 38%) had the second-stage LRYGBP. The mean number of co-morbidities in this group was 6.4 +/- 0.1 (reduced from 9). The ASA class of the majority of patients had been downstaged at the time of LRYGB. The mean time interval between the first and second stages was 12.6 +/- 0.8 months. The mean and median hospital stays were 3 +/- 1.7 and 2.5 (range 2-7) days, respectively. There were no deaths, and the incidence of major complications was 8%.
  
  
  CONCLUSIONS
  The staging concept of LSG followed by LRYGBP is a safe and effective surgical approach for high-risk patients seeking bariatric surgery.
authors.affiliation: Department of Surgery, University of Pittsburgh Medical Centre, Veterans Hospital, Pittsburgh, PA, USA.
authors.forename: D
authors.initials: D
authors.lastname: Cottam
authors.forename: F G
authors.initials: FG
authors.lastname: Qureshi
authors.forename: S G
authors.initials: SG
authors.lastname: Mattar
authors.forename: S
authors.initials: S
authors.lastname: Sharma
authors.forename: S
authors.initials: S
authors.lastname: Holover
authors.forename: G
authors.initials: G
authors.lastname: Bonanomi
authors.forename: R
authors.initials: R
authors.lastname: Ramanathan
authors.forename: P
authors.initials: P
authors.lastname: Schauer
mesh_terms: D015992:Body Mass Index; D005260:Female; D005743:Gastrectomy / Q000009:adverse effects / Q000379:methods*; D015390:Gastric Bypass / Q000009:adverse effects; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D008875:Middle Aged; D009767:Obesity, Morbid / Q000150:complications / Q000401:mortality / Q000503:physiopathology* / Q000601:surgery*; D012086:Reoperation; D018570:Risk Assessment; D013997:Time Factors; D016896:Treatment Outcome; D015431:Weight Loss