bariatric sleeve gastrectomy
DESCRIPTION
bedahTRANSCRIPT
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)
4
Laparoscopic Adjustable Gastric Banding (LAGB)
5
Biliopancreatic Diversion with Duodenal Switch (BPD-DS)
6
Roux-en-Y Gastric Bypass(RYGB)
7
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
10
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
15
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
16
Uses five or six ports
Surgical Technique
17
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