Sleeve Gastrectomy – A potential successor to the Lap RYGB? By John Liu - TUSM 3 Wednesday, December 10, 2008 General Surgery Clerkship Newton-Wellesley Hospital
Sleeve Gastrectomy – A potential successor to the Lap RYGB?
By John Liu - TUSM 3Wednesday, December 10, 2008
General Surgery ClerkshipNewton-Wellesley Hospital
Bariatric Surgery
In 1966, Dr. Edward Mason (Univ. of Iowa) performed the first gastric bypass operation
Goals Achieve better health by weight loss Minimize side effects and complications (strictures,
anastomotic leaks, nutritional deficiency, reoperations)
Bariatric Surgery – only proven method for achieving long term weight loss
-EWL 50% - Gold standard, EWL 49-70%- mortality rate up to 0.05% - mortality rate 0.15%
- no nutritional deficiency - moderate nutritional deficiency
-EWL 40-60% -EWL 80-90%- mortality rate up to 0.05% - mortality rate up to 1.9%
- no nutritional deficiency - severe nutritional deficiency
Laparoscopic Adjustable Gastric Banding Open or Lap. Roux-en-Y Gastric Bypass
- reoperative rate 25-50% - reoperative rate 5%
Vertical Banded Gastroplasty Biliopancreatic diversion with duodenal switch
- reoperative rate 14-43% - reoperative rate 4%
I. Braghetto, O. Korn, H. Valladares, L. Gutierrez, A. Csendes, A. Debandi, J. Castillo, A. Rodriguez, A. M. Burgos, L. Brunet. Laparoscopic Sleeve Gastrectomy: Surgical Technique, Indications and Clinical Results. Obesity Surgery. 17:1442-1450, 2007Marceau P; Hould FS; Simard S; Lebel S; Bourque RA; Potvin M, Biliopancreatic diversion with duodenalswitch., World journal of surgery. 1998 Sep;22(9):947-54
Sleeve Gastrectomy
Removal of 80% of the stomach Restrictive Procedure (can be converted to
combination malabsorptive with Duodenal Switch) Theoretically
Advantages: no nutritional deficiency, pyloris is preserved (no dumping), removal of ghrelin producing cells in gastric fundus
Disadvantages: ? %EWL, ? long-term results
SG and Endoscopic Intragastric Balloon (as a first stage procedure)
L. Milone, V. Strong, M. Gagner. Laparoscopic Sleeve Gastrectomy is Superior to Endoscopic Intragastric Balloon as a First Stage Procedure for Super-Obese Patients (BMI > 50). Obesity Surgery. 15:612-617, 2005
L S G
IB
Sleeve Gastrectomy and Gastric Banding
80 total subjects
median BMI & age:GB 37 & 36SG 39 & 40
p < 0.0001
J. Himpens, G. Dapri, G. B. Cadiere. A Prospective Randomized Study Between Laparoscopic Gastric Banding and Laparoscopic Isolated Sleeve Gastrectomy: Results after 1 and 3 Years. Obesity Surgery. 16:1450-1456, 2006
Sleeve Gastrectomy and RYGB
Karamanakos SN. Vagenas K. Kalfarentzos F. Alexandrides TK. Weight loss, appetite suppression, and changes in fasting and postprandial ghrelin and peptide-YY levels after Roux-en-Y gastric bypass and sleeve gastrectomy: a prospective, double blind study. Annals of Surgery. 247(3):401-7, 2008 Mar.
Ghrelin levels after SG and RYGB
Karamanakos SN. Vagenas K. Kalfarentzos F. Alexandrides TK. Weight loss, appetite suppression, and changes in fasting and postprandial ghrelin and peptide-YY levels after Roux-en-Y gastric bypass and sleeve gastrectomy: a prospective, double blind study. Annals of Surgery. 247(3):401-7, 2008 Mar.
700 400
Appetite Changes after Sleeve Gastrectomy and RYGB
Karamanakos SN. Vagenas K. Kalfarentzos F. Alexandrides TK. Weight loss, appetite suppression, and changes in fasting and postprandial ghrelin and peptide-YY levels after Roux-en-Y gastric bypass and sleeve gastrectomy: a prospective, double blind study. Annals of Surgery. 247(3):401-7, 2008 Mar.
Initial weight loss procedure for the super-obese (high risk patients with BMI > 60) Initial SG, an alternative to Gastric Banding prior to
RYGB to decrease comorbidities associated with complications during and after surgery2,3
Stand alone procedure for weight loss in patients with BMI 35-40
Indications for Sleeve Gastrectomy
Sleeve Gastrectomy – Surgical Technique
Lap Sleeve Gastrectomy – Surgical Technique
15 mm10 mm 12 mm
5 mm
I. Braghetto, O. Korn, H. Valladares, L. Gutierrez, A. Csendes, A. Debandi, J. Castillo, A. Rodriguez, A. M. Burgos, L. Brunet. Laparoscopic Sleeve Gastrectomy: Surgical Technique, Indications and Clinical Results. Obesity Surgery. 17:1442-1450, 2007
Lap Sleeve Gastrectomy – Surgical Technique
Lap Sleeve Gastrectomy – Surgical Technique
Lap Sleeve Gastrectomy – Surgical Technique
Lap Sleeve Gastrectomy – Surgical Technique
Start proximal to pyloris
Start proximal to pyloris
Staple towards incisura angularis
Stapling towards the Angle of His
Angle of His and Left Crus
Into the bag
Extracting the Gastric Fundus
Extracting the Gastric Fundus
The Specimen
Reinforce Staple Junctions
Check for Leaks
Conclusion
Simple – no anastamosis No malabsorption Hormonal appetite suppression Good short term weight loss Long term weight loss? Other long term implications?
Acknowledgements
Dr. Gazmuri and Dr. Partridge for their guidance and advice on this topic
Attendings – Dr. Biuckians, Dr. Cronin, Dr. Grady, Dr. Gryska, Dr. Kahan, Dr. Lanuti, Dr. Lawlor, Dr. Masiakos, Dr. Millham, Dr. Reinhorn, Dr. Sentissi, Dr. Vernon,
General Surgery Residents Jen LaFemina, Dzifa Kpodzo, Jonathon Greer, Sam Rodriguez, Becky, Hagit Bergman, Scott Regenbogen , Patty Cho, Evan Zucker, Aranya Bagchi, Rachel Robbins, Alex Hawkins,
General Surgery MS3&4 colleagues – KC Collins, Matthew Brady, Kate Anderson, Mika Sumiyoshi, Ben Caplan, Ken Roach, Emily Rosene, Betzalel Reich
Employees of NWH
Citations1. J. Himpens, G. Dapri, G. B. Cadiere. A Prospective Randomized Study Between Laparoscopic Gastric Banding and
Laparoscopic Isolated Sleeve Gastrectomy: Results after 1 and 3 Years. Obesity Surgery. 16:1450-1456, 20062. D. Cottam, F. G. Qureshi, S. G Mattar, S. Sharma, S. Holover, G. Bonanomi, R. Ramanathan, P. Schauer.
Laparoscopic Sleeve Gastrectomy as an Initial Weight-Loss Procedure for High Risk Patients with Morbid Obesity. Surgical Endoscopy. 20:859-863, 2006
3. A. Baltasar, C. Serra, N. Perez, R. Bou, M. Bengochea, L. Ferri. Laparoscopic Sleeve Gastrectomy: A Multi-Purpose Bariatric Operation. Obesity Surgery. 15:1124-1128, 2005
4. I. Braghetto, O. Korn, H. Valladares, L. Gutierrez, A. Csendes, A. Debandi, J. Castillo, A. Rodriguez, A. M. Burgos, L. Brunet. Laparoscopic Sleeve Gastrectomy: Surgical Technique, Indications and Clinical Results. Obesity Surgery. 17:1442-1450, 2007
5. Langer FB. Reza Hoda MA. Bohdjalian A. Felberbauer FX. Zacherl J. Wenzl E. Schindler K. Luger A. Ludvik B. Prager G. Sleeve gastrectomy and gastric banding: effects on plasma ghrelin levels. Obesity Surgery. 15(7):1024-9, 2005 Aug.
6. L. Milone, V. Strong, M. Gagner. Laparoscopic Sleeve Gastrectomy is Superior to Endoscopic Intragastric Balloon as a First Stage Procedure for Super-Obese Patients (BMI > 50). Obesity Surgery. 15:612-617, 2005
7. Karamanakos SN. Vagenas K. Kalfarentzos F. Alexandrides TK. Weight loss, appetite suppression, and changes in fasting and postprandial ghrelin and peptide-YY levels after Roux-en-Y gastric bypass and sleeve gastrectomy: a prospective, double blind study. Annals of Surgery. 247(3):401-7, 2008 Mar.
8. Marceau P; Hould FS; Simard S; Lebel S; Bourque RA; Potvin M, Biliopancreatic diversion with duodenal switch., World journal of surgery. 1998 Sep;22(9):947-54
9. M. Gagner, Minimally Edited Laparoscopic Sleeve Gastrectomy, 10. William B. Inabnet, Eric J. DeMaria, Sayeed Ikramuddin. Laparoscopic Bariatric Surgery. Published by Lippincott
Williams & Wilkins, 200411. Himpens J. Dapri G. Cadiere GB. A prospective randomized study between laparoscopic gastric banding and
laparoscopic isolated sleeve gastrectomy: results after 1 and 3 years. Obesity Surgery. 16(11):1450-6, 2006 Nov.