Laparoscopic Sleeve Gastrectomy

Dr Girish juneja Head of surgery deptt. Specialist laparobariatric surgeon Al Noor Hospital, abu dhabi, uae

SG was developed as a modification of the biliopancreatic diversion in 1988

1999 SG was first performed by laparoscopy, as part of BPD-DS, by Michel Gagner

This operation became an independent procedure when it was found that supersuper-obesity (BMI _ 60 kg/m2) and male gender were associated with elevated morbidity and mortality when those patients underwent BPD-DS.

2000, Gagner first proposed the SG as the first step of a two-stage laparoscopic duodenal switch as an alternative to this high-risk group of patients to decrease morbidity and mortality

LSG2003, SG was proposed as the first step of a

two-stage laparoscopic Roux-en-Y gastric bypass (LRYGB)

Since then, many surgical teams have already adopted this procedure with good results.

SG produces weight loss by two mechanisms1- produces early satiety as a purely restrictive

procedure 2- reduces plasma ghrelin levels by removing a

great part of the Ghrelin production tissue. - Ghrelin is a 28 amino-acid-peptide, secreted by

the oxyntic glands of the gastric fundus - potent orexigenic (appetite-stimulating)

hormone. - In SG, resection of the fundus removes the

major site of ghrelin release, therefore appetite decreases

KEY POINTS

• Sleeve gastrectomy causes a volume reduction of the stomach by 80 percent or more.

• It decreases serum ghrelin and leptin levels, increases GLP-1 and PYY 3-36,and reverses type 2 diabetes in the majority of cases.

Gastric and intestinal transit time appears to be reduced, causing an early stimulation of the distal GI tract.

LSG

LSG

Gastric sleeve resection techniqueTotal excision of fundusSparing of antrumTransection of stomach just lateral to lesser

curve vessels endingsOversewing entire staple line?Staple line reinforcement ?

Technique of SleeveGastrectomy

Anatomy

“Three Angles” Surgeons must pay special attention1. The Incisura angularis or the angle of the stricture.2. The gastrosplenic ligament or the angle of bleed 3. The Angle of His or the angle of the leak

LSG

Port placement

start by dividing the greater omentum with the ultrasonic shears at a midpoint along the greater curvature

The branches of the gastroepiploic artery are divided near the gastric wall

We then proceed with the division of the short gastric vessels that is performed up to the fundus

L. S.G.

L.S.G.

LSG-debatable points First stage or definitive Sleeve Calibration (bougie size)Distance from pylorus to initiate sleeve Oversewing entire staple line?Staple line reinforcement ?Section shape at OG junctionRoutine use of intraoperative leak testingRoutine versus selective upper GI series for

leak testHigher rate of leaks after revisional surgery

FIRST STAGE OR DEFINITIVE

LSG has become safe & effective both as a first stage bariatric procedure in high risk or superobese pts

& as a primary operation

KEY POINTSIn BPD-DS maximal gastric pouch or tube of

150 to 200 mL

In SG isolated procedure, the gastric pouch size usually varies from 50 to 120 mL, depending on the size of the bougie we introduce into the stomach to perform the SG.

Long term resultsFive-year EWL after sleeve gastrectomy is 50 to 55 percent. A subset of patients will require a second-

stage bypass procedure to achieve optimal weight loss after sleeve gastrectomy.

High BMI, high-risk patients can achieve excellent long-term weight loss

. STACY A. BRETHAUER & PHILIP R. SCHAUER

obesity times 2011;8

Long-term Results After Laparoscopic Sleeve Gastrectomy EWL was 72.8% (±25.6) after three years

and 57.3% (±29.1) after 6 years(p=0.0017). BMI increased from 27.3 kg/m2 (±5.0) at

three years to 30.1kg/m2 (±6.5) at six years(p=0.0050)

JACQUES HIMPENSBariatric Times. 2011;8(5 Suppl):11–12

Long-term Results After Laparoscopic Sleeve GastrectomyLSG has a failure rate of 43% after 6+years.

One out of four patients develops GERD symptoms after 6+ years.

Treatment can be either resection of a neo-fundus or Roux-en-Y gastric bypass.

DS constitutes an effective solution for poor weight loss or weight regain after LSG.

JACQUES HIMPENSBariatric Times. 2011;8(5

Suppl):11–12.

LSG-debatable points First stage or definitive Sleeve Calibration (bougie size)Distance from pylorus to initiate sleeve Oversewing entire staple line?Staple line reinforcement ?Section shape at OG junctionRoutine use of intraoperative leak testingRoutine versus selective upper GI series for

leak testHigher rate of leaks after revisional surgery

Sleeve Calibration (bougie size)

EWL with varying bougie size

Auther preop bougie 6m EWL 12m EWL

Mognol 64 32 41% 51%

Lee et al 49 32 NA 59%

Himpens 39 34 NA 58%

Langer 49 48 46% 56%

Parikh surg obesity relat 008;4

Calculation of volume of 25cm long gastric tube based on varying bougie size(excluding antrum)Bougie diameter volume 32 f 1cm 20cc36f 1.2 cm 26 cc40f 1.3cm 32 cc50f 1.6 cm 50 cc

60f 1.9cm 71cc Parikh surg obesity relat

2008;4

BOUGIE SIZE

For all LSG as part of a BPD-DS, used the 60-Fr bougie to ensure adequate protein intake.

For primary LSG, we use a 36-Fr bougie but it could be smaller or greater (28-54 Fr).

LSG Distance from pylorus to initiate

sleeve

2cms– 6 cms

LSGThere is a trend towards smaller bougie(32 f)

& Initiating sleeve 2cm px to the pylorus, for a more restrictive effect.

LEAK Meta analysis 4888cases & 29 publications Overall leak rate 2.4%Superobese BMI>50 2.9%for BMI < 50 2.2%BOUGIE 40 F - 0.6% <40F 2.8%SITE OF LEAK – PX THIRD 89%Staple height& buttressing material– no effectMost leaks were diagnosed after discharge surg endosc 2011: dec.

17

STAPLE LINE REINFORCEMENT?

*STAPLE –LINE BUTTRESSING SIGNIFICANTLY INCREASED STAPLE LINE STRENGTH

*DECREASES BLEEDING

STAPLE LINE REINFORCEMENT?

Reinforcement does not necessarily reduce the rate of staple line leaks after sleeve gastrectomy.

Obes Surg. 2009 Feb;19(2):166-72.

STAPLE LINE REINFORCEMENT? IFSO 2010

Michele Gagner reduces rate of leak

OVERSEWING

Full thickness over sewing of staple lines significantly weakened all staple lines

Risk of tearing

Baker RS et al,obes surgery,2004,14

Section shape at OG junctionAt the uppermost portion of the stomach, the

transection line is allowed to deviate away from the bougie to avoid severe stenosis at the gastroesophageal junction but going further from the bougie may lead to fundus dilation and weight regain

Incorporation of esophagus can weaken the staple line

Section shape at OG junction

Routine UGI contrast study very low sensitivity(50%) to detect leakExpansive Sometimes fails to detect

M.schiesser ,obesity surgery,vol-21,1238