it is accepted that surgical treatment of super superobese patients ( bmi > 60  kg / m ) and high - risk patients with comorbidities , is responsible for an increased risk of postoperative morbidity and mortality after bariatric surgery [ 1 , 2 ] .  
sleeve gastrectomy is a recently used surgical technique , with an acceptable rate of postoperative complications .
it has been described as a first step before a gastric bypass or biliopancreatic diversion with duodenal switch .
the restrictive technique of sleeve gastrectomy reduces the gastric capacity by approximately 80% . in his study
this is a prospective study that included 30 consecutive super superobese patients and was designed to study the efficacy and safety of the sleeve gastrectomy in this group of these patients .
for the 30 super superobese patients , we evaluated : the duration of intervention , the early ( less than 30 days ) and late postoperative complications , hospital stay , loss of excess weight ( % ewl ) , and the need for a second operation in the case of insufficient weight loss .  
all patients were operated by laparoscopy , and they were placed in the operating table according to the french position ( the surgeon was positioned between the legs of the patient ) .
the greater curvature of the stomach was freed with the ligasure ( covidien , norwalk , ct , united states ) until the angle of hiss .
the left crura of the diaphragm was systematically visualised and posterior attachments of the stomach released .
a 34 french boogie was introduced into the stomach and positioned along the lesser curvature .
the stomach was cut with an incision parallel to the boogie using a linear stapler ( endo gia 45 covidien , 4.8  mm , norwalk , ct , united states ) . in each case , the resected stomach was placed in a plastic bag and was extracted via the umbilical trocar .
staple line was consistently reinforced by a nonabsorbable suture ( endostich surgidac-2/0 , covidien , norwalk , ct , united kingdom ) .
the fascia of each port site greater than 12  mm in diameter was always closed .
cautious refeeding was permitted in the absence of fistula , and patients were discharged after removal of the drain .
iron , vitamin , and essential mineral supplements were systematically given to the patient at their discharge .
all patients were super superobese with a mean bmi of 66  kg / m ( range from 60 to 85  kg / m ) .
one patient had a complete situs inversus and 4 others ( 14% ) had previous gastric banding .  
immediate postoperative complications occurred in 4 patients ( 14% ) : two presented subphrenic hematomas , one developed a gastric fistula , and one had pulmonary embolism .
all three surgical complications required the creation of a laparoscopic drainage with no need for further surgical treatment .  
of the 23 patients that had a followup greater than 18 months , weight loss was satisfactory in 17 patients ( 77% ) .
six patients had insufficient weight loss defined by a bmi between 35 to 40  kg / m , progressive weight regain or persistence of comorbidities supposed to improve with further weight loss .
if the patient gave his consent for a second operation , then a gastro - intestinal contrast study was performed , in the presence of a dilated gastric pouch due either to incomplete gastric resection or to the persistence of hyperphagia responsible for a mechanical dilation a resleeve was proposed , otherwise , the choice of a gastric bypass was made ( figure 1 ) .
the choice of resleeve as a revisional surgery was made for 2 reasons firstly it is reasonable to reoperate a stomach when there is still a secondary gastric pouch a known cause of weight loss failure and secondly , resleeve according to our previous experience , although we do not have a long term followup , has been shown to have better results associated to less morbidity and mortality rates for superobese patients .
three out of six patients were reoperated with a resleeve gastrectomy , and two with a gastric bypass surgery 18 to 23 months after the initial procedure .
three years after the original sleeve gastrectomy , the average loss of bmi was 20  kg / m ( range 10 to 39  kg / m , figure 2 ) .
the average percentage of excess weight loss at 3 years was 51% ( range 2182% , figure 3 ) , while the average weight loss was 56  kg ( range 28144  kg ) ( figure 4 ) . during the followup
, a port site hernia requiring surgical treatment was observed in 2 patients ( 7% ) .
perioperative risks ( morbidity and mortality ) are known to be high for patients with super superobesity .
the multidisciplinary team preoperatively should carefully evaluate the benefit / risk ratio of bariatric surgery in any given patient .
gastric banding presents less risk but is also less effective in super superobese patients . gastric bypass and biliopancreatic diversion
although associated to a higher morbidity ratio demonstrate excellent efficiency in regard to weight loss .
the magenstrasse technique uses a longitudinal section of the stomach without gastric resection has been proposed in super superobesity because of its lower morbidity and mortality . this procedure that divides the stomach into two compartments
preliminary results showed that the sleeve gastrectomy , after a 24-month period postroperatively was equally effective as gastric bypass in terms of weight loss in the super superobese patients while presenting lower risk for complications ( 3,6% to 9% resp . ) .
the frequency of complications after gastric bypass in the super superobese can reach up to 23%   and up to 38% for duodenal switch . in the super superobese patients ,
the death rate was assessed up to 2.7% after gastric bypass   and 6.25% after duodenal switch . among our 30 patients
, we had 3 immediate postoperative complications like hematoma or fistula that were successfully treated with laparoscopic drainage .
current studies on the sleeve gastrectomy have published an average followup of less than 3 years [ 7 , 9 , 10 ] while two separate studies [ 6 , 9 ] using a stapler line reinforcement , that is , the same technique with our team , reported also no postoperative morbidity and mortality .  
the initial rapid weight loss , reported by previous studies [ 4 , 9 , 11 ] , reached a plateau at 18 months after surgery .
we found the presence of insufficient weight loss in only 23% of patients at 18 months . in our group of 30 patients , 23 had a followup more than 18 months , 5 had a second operation 3 of them had a resleeve gastrectomy and 2 a gastric bypass .
it is known that the sleeve gastrectomy in the super superobese can be a definitive treatment for an average loss of excess weight by 50% at one year [ 3 , 10 ] .
we have shown that the sleeve gastrectomy for the super superobese can allow an average loss of excess weight by 53% at 18 months . if weight loss was insufficient , the sleeve gastrectomy
could then be followed by a second operating procedure , like gastric bypass   or biliopancreatic diversion .
the second operation presented less technical difficulties thanks to the weight loss already achieved since the first sleeve gastrectomy .
five patients were operated for a second time , three of them had a resleeve gastrectomy , and two a gastric bypass as a second - step procedure .
although we present a small group in this study , there were no postoperative complications associated to the excellent weight loss and these results demonstrate the efficacy as well as the safety of the second intervention .  
it is known that bariatric surgery provokes weight loss through dietary restriction or through the malabsorption it imposes .
the mechanisms responsible for decreased appetite are poorly understood . to make things more complicated some of the excellent early results like the decrease in blood sugar and insulin resistance seem to be independent from the weight loss .
a great interest has been reported for the role of ghrelin , a hormone that is secreted by the gastric fundus a part of the stomach that is largely resected in a sleeve gastrectomy .
ghrelin is secreted under the influence of cholinergic stimulation and has probably a major role in controlling appetite since its receptors are present in the pituitary and hypothalamus . in humans ,
the serum concentration of ghrelin is increased in anorexia nervosa , prader willi syndrome , and in patients with a reduced caloric diet .
ghrelin 's concentrations are decreased by food intake and after gastrectomy or gastric bypass [ 13 , 14 ] .
the absence of contact between food and the lining of the stomach producing ghrelin inhibits its secretion . in the case of sleeve gastrectomy
, the removal of the ghrelin - producing area could eventually explain the weight loss .
two separate studies reached the same conclusions with our team and have provided evidence for both an early and late ghrelin decrease after the sleeve gastrectomy [ 16 , 17 ] .
 
 objective . 
 this prospective study evaluated laparoscopic sleeve gastrectomy for its safety and efficiency in excess weight loss ( % ewl ) in super superobese patients ( bmi > 60  kg / m2 ) . 
 results . 
 thirty patients ( 33 women and 7 men ) were included , with mean age of 35 years ( range 18 to 59 ) . 
 mean preoperative bmi was 66 kg / m2 ( range 60 to 85 ) . 
 the study included one patient with complete situs inversus and 4 ( 14% ) with previous restrictive gastric banding . 
 the mean operative time was 120 minutes ( range 80 to 220 min ) and the mean hospital stay was 7.5 days ( 4 to 28 days ) . 
 there was no postoperative mortality or need for a laparotomy conversion . 
 two subphrenic hematomas , one gastric fistula , and one pulmonary embolism , were the major complications . 
 after 18 months 17 ( 77% ) had sufficient weight loss and six had insufficient results , leading to either re - sleeve gastrectomy ( 3 ) , or gastric bypass ( 2 ) . 
 three years after the initial laparoscopic sleeve gastrectomy , the mean ewl was 51% ( range 21 to 82 ) . conclusion . 
 the laparoscopic sleeve gastrectomy is a safe and efficient operating procedure for treating super superobesity . in the case of insufficient weight loss , 
 a second - stage operation like resleeve gastrectomy or gastric bypass can be proposed . 
1. Introduction
2. Methods
3. Results
4. Discussion