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.