Bariatric Sleeve Gastrectomy

Name : dr. Errawan R. Wiradisuria, SpB-KBD, M.Kes Birth Place & Date : Bandung (Indonesia), April 2nd, 1957 Present Position : General Surgeon, Consultant in Digestive and Laparoscopic Surgery

FORMAL EDUCATIONGeneral Practitioner : Faculty of Medicine, University of Padjadjaran, Bandung - Indonesia (March, 23rd, 1983)

General Surgeon : Dept. of Surgery, Faculty of Medicine University of Indonesia/Cipto Mangunkusumo Hospital, Jakarta - Indonesia (Oct., 08th ,1991)

Digestive Surgeon : Div. of Digestive Surgery, Dept of Surgery Faculty of Medicine, University of Indonesia/Cipto Mangunkusumo Hospital, Jakarta Indonesia (May, 20th, 1997)

Magister of Hospital Management : Faculty of Public Health, University of Gadjah Mada, Yogyakarta Indonesia (April, 24th, 2008)

Curriculum Vitae

ACTIVITY (IN ENDO-LAPAROSCOPIC SURGERY FIELD)

July 1997 - now: Member of Endoscopic Laparoscopic Surgeons of Asia (ELSA)2002 - now: Executive Council Member (Governor) of ELSA1997 - now: Instructor (Faculty Member) in many Laparoscopic Surgery Courses (organized by ISES)1998 - now: Member of International Hepato-Pancreato-Biliary Association (IHPBA)Aug. 2006 - now : Board of Member Asia Endosurgery Task Force (AETF).Oct. 2007 - now : Live Member of Asia Pacific Hernia Society (APHS).May 2008 - now: President of Indonesian Society of Endo-Laparoscopic Surgeons (ISES/PBEI) 2008 2012 & 2012 - 2016May 2008 - now : Secretary General of Indonesian Hernia SocietyDec. 2008 - now: Editor member of Asian Journal of Endoscopic SurgeryOct. 2009 - now: International Member of SAGES (Society of American Gastrointestinal and Endoscopic Surgeons)2010 - now : Chairman Of Advance Laparascopic Surgery Courses (Asia-Pacific), Bali International Training and Development Center (BITDEC), Tanah Lot, BaliDec 2011 - now: Secretary General of Indonesian Society of Digestive Surgeons (IKABDI)March 2012 - now: Member of ASCS (ASEAN Society of Colorectal Surgeons - Indonesian Representative) March 8 - 10th, 2012 : Chairman of SAGES Scientific Plennary Session (Laparoscopic Surgery In Solid Organ), San Diego, CA, USAMarch 28th, 2013 : Chairman of AETF Scientific Workshop (Laparoscopic Colorectal Surgery), Fujinomia, Tokyo, Japan)April, 2013: Observer in Department of HBP, MAYO CLINIC, Jacksonville, Florida, USA.Nov. 2013 - 2015: Vice President of ELSA (Endoscopic Laparoscopic Surgeons of Asia)Oct. 9 - 12th, 2014: President of The International Congress of ELSA, Bali, Indonesia.

Bariatric Sleeve GastrectomyErrawan Wiradisuria

PrefaceBariatric surgery, aimed at weight reduction, has been proven to be a viable option for the treatment of severe obesity in comparison to conservative methods, resulting:Long-lasting weight lossImproved quality-of-lifeResolution of obesity-related co-morbidities1

Superiority of laparoscopic bariatric surgery:Reducing impairment of post-operative pulmonary functionReduced intra-operative blood lossReduced hospital stayReduced wound infection and incisional hernia rateQuick recovery and return to workDecrease of postoperative venous thrombo-embolismImproved Safety2

Indication of Bariatric SurgeryBMI > 35

BMI > 30 with high risk comorbid conditions or lifestyle-limiting obesity-induced physical conditions

*Park Y J, Kim J Y., ASTR Journal. 2015 3

Types of Bariatric SurgeryLaparoscopic Adjustable Gastric Banding (LAGB)

Biliopancreatic Diversion with Duodenal Switch (BPD-DS)

Roux-en-Y Gastric Bypass (RYGB)

Laparoscopic Sleeve Gastrectomy (LSG)

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Laparoscopic Adjustable Gastric Banding (LAGB)

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Biliopancreatic Diversion with Duodenal Switch (BPD-DS)

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Roux-en-Y Gastric Bypass(RYGB)

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Laparoscopic Sleeve Gastrectomy (LSG)

* www.centro-obesi.com; online.epocrates..com8

Bariatric SurgeryRecently, decrease in the acceptance of LAGB, because:

Need the absolute patient compliance

Need long term observation and evaluation

High revision rate

High request rate to withdraw the banding (reversible procedure)

*Buchwald H.O., Obes surg. 2013;23(4):427-4369

Laparoscopic Sleeve GastrectomyA vertical gastrectomy that leaves a narrow gastric tube along the lesser curvature of the stomach (removal of 75% of the stomach)

Was first described by Marceu et al (1990)

LSG has a similar efficacy of weight reduction comparing to RYGB and BPD-DS

Accepted as a primary procedure because its simplicity and effectiveness compared with other bariatric procedures

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Retention of vagal innervation along the lesser curvature preserve regulation of gastric emptying & the gastroduodenal contribution to satiety

Reduction of the parietal cell mass minimize the incidence of marginal ulcers

However, the main long-term drawback of LSG is the development of gastro-esophageal reflux disease (GERD) in around 15% of the patients

*Lee W.J, Almulaifi A., The Journal of Biomedical Research. 2015, 29(2):98-104Mechanism of LSG11

Mechanism of LSG* GLP-1 (Glucagon-like Peptide 1)12* Nguyen NT, et al. The ASMBS Textbook of Bariatric Sugery. Vol 1. 2015

Mechanism of LSGInsulin13* Nguyen NT, et al. The ASMBS Textbook of Bariatric Sugery. Vol 1. 2015

Reduction of HbA1c

Reduction of hypertension

Cardiac remodelling (left ventricular mass , septum & posterior wall thickness )

Lipid profile improvement (HDL & TG levels, total cholesterol/HDL ratio & TG/HDL ratio)Metabolic Outcomes of LSG14

Greater excess weight lossImprovement in diabetes

Why Sleeve Gastrectomy?Compared to LAGBCompared to BPD-DS & RYGBRelative simple techniqueLow morbidityEndoscopic access to the GITAbsence of anastomosesMinimal nutritional deficienciesExcellent weight loss with control of associated comorbiditiesPossibility to convert to other procedures

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Patient in supine & legs spread (French position), in a steep Fowler (reverse Trendelenburg) position

Anti-embolic stockings & intermittent compression devices to prevent venous thromboembolism

Surgical Technique

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Uses five or six ports

Surgical Technique

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Surgical Technique

18* Nguyen NT, et al. The ASMBS Textbook of Bariatric Sugery. Vol 1. 2015

A 10-mm, 30o scope is used, left liver lobe retracted: expose the entire GE junction + lesser curve

Start cutting the small branches of the gastroepiploic arcade and opening the lesser sac. Dissection along the greater curve, dividing the branches of both gastroepiploic arteries, until short gastric vessels

Surgical Technique19

Remain of the gastrocolic ligament (no gastroepiploic vessels transection) is severed distally up to 2 cm proximal to the pylorus

Stomach lifted to expose its posterior aspect, and all lesser sac attachments of the stomach are freed

Surgical Technique20

Aware of the presence of the branches of the left gastric artery

Aware of the spleen artery and vein

Divide gastrophrenic ligament & expose the angle of His to determine the presence of hiatal hernia

In case a hiatal hernia is discovered, release the distal esophagus from mediastinal attachments and brought down into the abdomen. Posterior crural approximation is conducted to close the gap (nonabsorbable suture)

Surgical Technique21

Stomach division starts 4 cm proximal to the pylorus

The anesthesist introduces a 34-40 Fr bougie to guide the stapling and maintain an adequate lumen of the gastric sleeve

The bougie should be placed prior to stapling, guiding it to reach the pylorus and positioned close to the lesser curve

The stomach is held by the assistant stretching it to the patients left

Surgical Technique22

Cut the fundus at least 1 cm from the gastroesophageal junction

The integrity of the staple line is tested with the instillation of 100-200 ml of methylene blue in saline solution

Surgical Technique23* Nguyen NT, et al. The ASMBS Textbook of Bariatric Sugery. Vol 1. 2015

Rapid reversal of diabetes, hypertension, hyperlipidemia and obesity by surgical means has challenged accepted doctrines regarding the management of metabolic syndrome

Conclusion24

LSG as an effective lone laparoscopic & procedure of choice for patients and surgeons, because of:Relatively simple procedureSuperior excess weight lossLow complication rateExcellent food toleranceShort hospital stay

Conclusion25

Photo Session

Thank You