+

Roles of Laparoscopic

Sleeve Gastrectomy in

Bariatric Surgery

Vincent Lau

TKOH

+Obesity is a global pandemic!

Age-standardised prevalence of overweight and obesity and obesity alone, ages ≥20 years, by sex, 1980–2013Ng M, Fleming T, Robinson M et al. Lancet 2014;384:766-781

+We are not only the second in World’s GDP, but also…

+Obesity cause 3.4 Millions death in 2010

+Prevalence of type 2 DM and We have near 1,400,000,000 people!

11.9% 9.3%

+The BMI threshold for Bariatric Surgery is now: 27.5

IFSO-APC Consensus Statements 2011

BMI ≥27.5 + DM or metabolic syndrome

1991 NIH Consensus Statement

BMI > 40

BMI > 35-40 + severe comorbids

Bariatric Surgery needs YOU!

+Laparoscopic Sleeve Gastrectomy

Significant weight loss

DM remission rate comparable with gastric bypass

Relative Safer

Shorter learning Curve

+LSG is increasing performed worldwide in just last few years!

+Laparoscopic sleeve gastrectomy as an initial weight-loss procedure for high-risk patients with morbid obesity.

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 And Other Interventional Techniques: June 2006, Volume 20, Issue 6, pp 859-863

+Laparoscopic sleeve gastrectomy as an initial weight-loss procedure for high-risk patients with morbid obesity.

  Preop12 mo after stage I

6 mo after stage II

p value

Mean weight (kg)

177 131 109 <0.05

Body mass index

65 ± 9 49 ± 8 39 ± 8 <0.05

Co-morbidities

9 ± 3 6 ± 3 2 ± 1 <0.05

ASA ≥ 3 94% 44% NA <0.05

+BMI Is Predictive of Higher In-hospital Mortality in Patients Undergoing Laparoscopic Gastric Bypass but Not Laparoscopic Sleeve Gastrectomy or Gastric Banding

For gastric bypass, there was an increased of in-hospital mortality (0.01 and 0.02 vs 0.34%; P< 0.01) and major complications (0.93 and 0.99 vs 2.6%; P< 0.01) in the BMI 60kg/m2 or greater group.

Villamere J, Gebhart A, Vu S et al. Impact of BMI in Laparoscopic Bariatric Surgery. The American Surgeon 2014; 80: 1039-43

Local data: Stand-alone LSG with maximal follow-up up to 6 years

EWL: by 64.5 ± 21.4%

Mean Trough BMI 29.5 ± 4.5kg/m2

↓ DM 58%

↓ HT 23%

↓ LDL-C

↓ TG

↑ HDL-C

All P< 0.05 by paired T tests

49 patients, 17M & 32F

Mean age:44.8 ± 8.9 years

Mean BMI: 39.8 ± 4.5kg/m2

Mean FU period : 39.8 ± 4.5 months

75% DM patients 86% HT

Duration from OT to trough weight 14.3 ± 8.3 months

+Excess Weight Loss after Sleeve Gastrectomy: A systematic reviews

Fischer L, Hildebrandt C, Bruckner T et al. Obesity Surgery;2012:22:721-731

+36 Papers ( n≥100 ) involving 8,785 patients

+% EWL is Similar between LSG and LRYGB

Kehagias I, Karamanakos SN, Argentou M, et al. Randomized Clinical Trial of Laparoscopic Roux-en-Y Gastric Bypass Versus Laparoscopic Sleeve Gastrectomy for the Management of Patients with BMI<50 kg/m2. Obesity Surgery;2011:21:1650-1656

© 2013 by Lippincott Williams & Wilkins. 2

TABLE 1

Early results of the Swiss Multicentre Bypass or Sleeve Study (SM-BOSS): a prospective randomized trial comparing laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass.Peterli R; Borbely Y; Kern B; Gass M; Peters T; Thurnheer M; Schultes B; Laederach K; Bueter M; Schiesser M

Annals of Surgery. 258(5):690-4; discussion 695, 2013 Nov.DOI: 10.1097/SLA.0b013e3182a67426

TABLE 1 . Patient Descriptives

© 2013 by Lippincott Williams & Wilkins. 4

FIGURE 1

Early results of the Swiss Multicentre Bypass or Sleeve Study (SM-BOSS): a prospective randomized trial comparing laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass.Peterli R; Borbely Y; Kern B; Gass M; Peters T; Thurnheer M; Schultes B; Laederach K; Bueter M; Schiesser M

Annals of Surgery. 258(5):690-4; discussion 695, 2013 Nov.DOI: 10.1097/SLA.0b013e3182a67426

FIGURE 1 . A, Change in BMI (means +/- standard error). B, EBMIL (means).

+LSG Results in 80% DM remission as compared to Medical Treatment 30 patients in each group

All diabetic with morbid obesity

BMI: LSG:41.3±6 kg/m2 ; medical treatment 39±5.5 kg/m2

Post LSG: BMI 28.3± 5.4kg/m2 at 18 months,

80% DM remission

Leonetti F, Capoccia D, Coccia F et al. Obesity, type 2 Diabetes Mellitus, and other comorbidites;:A prospective cohort study of laparoscopic sleeve gastrectomy vs medical treatment. Arch Surg 2012:8:694-700

+LSG is Better than Laparoscopic Adjustable Gastric Banding

LSG Mean EWL: 50.6% and

51.8% at 6 and 12 months

DM improved in 82.5.% DM patients

LABG Mean EWL: 33.9% and

37.8% at 6 and 12 months

DM improved in 61.8% DM patients

Wang S, Li P, Xiao F et al. Comparison between laparoscopic sleeve gastrectomy and laparoscopic adjustable gastric banding for morbid obesity: a meta-analysisObesity Surgery. 23(7):980-6,2013 Jul.

© 2013 by Lippincott Williams & Wilkins. 5

FIGURE 2

Early results of the Swiss Multicentre Bypass or Sleeve Study (SM-BOSS): a prospective randomized trial comparing laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass.Peterli R; Borbely Y; Kern B; Gass M; Peters T; Thurnheer M; Schultes B; Laederach K; Bueter M; Schiesser M

Annals of Surgery. 258(5):690-4; discussion 695, 2013 Nov.DOI: 10.1097/SLA.0b013e3182a67426

FIGURE 2 . Reduction in comorbidity 1 year after surgery. No significant difference in cure or improvement of comorbidities between LSG and LRYGB except for GERD (*P = 0.008). GERD indicates gastro esophageal reflux disease; OSAS, obstructive sleep apnea syndrome; T2DM, type 2 diabetes.

+GBP vs SG

GBP Mean EWL 72.5% at 12

months DM remission:

67% at 3 months 76% at 12 months 81% at 36 months

SG Mean EWL 66.7% at 12

months DM remission:

56% at 3 months 68% at 12 months 80% at 36 months

Yip S, Plank L, Murphy R. Gastric bypass and sleeve gastrectomy for type 2 diabetes: a systematic review and meta-analysis of outcomes. Obesity Surgery.2013;23:1994-2003

+LSG as a Revisonal Procedure after Adjustable Gastric Band?

Similar EWL % as compared with revision to LRYGB.

Ranging from 23% to 74%

Higher complications rate as primary procedures

All the included studies are cohort studies.

Coblijn UK, Verveld CJ,van, Wagensveld BA et al. Laparosopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy as Revisional Procedure after Adjustable Gastric Band- a Systematic review. Obesity Surgery 2013;23:1899-1914

+Thank You!

© 2013 by Lippincott Williams & Wilkins. 3

TABLE 2

Early results of the Swiss Multicentre Bypass or Sleeve Study (SM-BOSS): a prospective randomized trial comparing laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass.Peterli R; Borbely Y; Kern B; Gass M; Peters T; Thurnheer M; Schultes B; Laederach K; Bueter M; Schiesser M

Annals of Surgery. 258(5):690-4; discussion 695, 2013 Nov.DOI: 10.1097/SLA.0b013e3182a67426

TABLE 2 . Perioperative Morbidity

+EWL of Sleeve, gastric band and gastric bypass in systemic reviews

+RYGB and SG

Alter the defended level of body weight

Preventing normal responses to food restriction that make maintaining significant non-surgerically induced weight loss so difficult

Both associated with metabolic improvement that are distinct from those that are caused by weight loss alone

Similar effects on key metabolic parameters, ingestive behavior, gut hormone secretion

+LSG vs LSG+DS BMI 48±9%

DM: 51%

HT: 62%

OSAS 63%

378 patients,

EWL at 1 year 53 ± 18% at 12 months,

EWL 50±19% at 2 years, and

EWL at 51±24% vs 83%±16% at 3 years

DM remission: 56% vs 90%; HT remission 54% vs 76%; OSAS 43% vs 74%

One 30 days mortality from PE, 30 days complications occurred in 6% vs 8% (P= 0.2)

BMI: 48±6%

DM: 37%

HT: 49%

OSAS 51%

422 patients

EWL at 1year: 81 ±14%

EWL at 2 years:

EWL at 3 years: 83±16%

+

LSG alone: significant 3 years weight loss, and remission of co-morbidities

BPD+DS: provides further improvement of associated co-morbidites

Biertho L, Lebel S, Marceau S et al. Laparoscopic sleeve gastrectomy: with or without duodenal switch? A consecutive series of 800 cases. Digestive Surgery. 31(1):48-54, 2014

+

　 Table 1. 　 　 　 　 　 　 　 　Early and late complications after adjustable gastric banding, gastric bypass, and sleeve gastrectomy.

AGB % Ref. SG % Ref. GBP % Ref.

Early 　 　 　 　 　 　 　 　　 　 　 Leak 3.4[97] Leak 3.6[37]

　 　 　 Bleeding 2.4[27] 　 　 　　 　 　 Stricture 2.4[27] 　 　 　Death 0[37] and [98] Death 0.08[14] Death 0.2[37]

Late 　 　 　 　 　 　 　 　Ablation 60[40] Reflux 23[27] Obstruction 3.1[99]

Migration/Erosion 1.6[100] 　 　 　 Dumping 13.3[34]

Slippage 12.5[101] 　 　 　 abdominal pain 9.8[34]

Port 8.4[102] 　 　 　 　 　 　%EWL< 50% 50[46] %EWL < 50% 33[103] %EWL < 50% 23[32]

+GBP vs SG 1

Studies published between 1 Jan 2007 and 30 April 2012

1375 patients, 3 RCT and 18 prospective and 12 retrospective studies

Yip S, Plank L, Murphy R. Gastric bypass and sleeve gastrectomy for type 2 diabetes: a systematic review and meta-analysis of outcomes

+Weight and Type 2 diabetes after Bariatric Surgery Systematic review and meta-analysis

Buchwald H, Estok R, Fahrbach K et al. The American Journal of Medicine 2009;122:248-256

Table 8. 　 　 　 　 　

Overview of Weight Loss, Surgical Procedure, and Diabetes Resolution

　 Total Gastric Banding Gastroplasty Gastric Bypass BPD/DS

% EBWL 55.9 46.2 55.5 59.7 63.6

% Resolved overall 78.1 56.7 79.7 80.3 95.1

% Resolved <2 y 80.3 55 81.4 81.6 94

% Resolved ≥2 y 74.6 58.3 77.5 70.9 95.9

+

+Fig. 1 Forest plot of comparison: (1) LAGB vs LSG in terms of short-term results, outcome: (1.1) resolution of diabetes. Odds ratios are shown with 95 % CIs

+Evolution of Sleeve Gastrectomy