SLEEVE GASTRECTOMY:

ANATOMIA DI UN DILEMMA TERAPEUTICO

IntroductionLaparoscopy achieves the same anatomic objectives as open bariatric surgery but avoids a large abdominal incision Bariatric surgery is the most effective method for achieving sustained weight loss of considerable degree in individuals with morbid obesitySurgeons should have a clear understanding of the four most commonly discussed operations for morbid obesity at this time:

1)Laparoscopic Roux-en-Y gastric bypass (LRYGB)

2)Laparoscopic adjustable gastric banding (LAGB)

3)Duodenal switch (DS)

4)Laparoscopic sleeve gastrectomy (LSG)

General overview of the various laparoscopic procedures for morbid

obesity

“La chirurgia dell obesita e accetabile

solamente se e efficace e sicura”

EFFICACITA

Perdita di al meno 50% del eccesso ponderale a 1 anno e a 3 anni

SLEEVE GASTRECTOMY

2000

come “ first step”

nelle

“ two stages” procedure

Cauto ottimismo entusiasmo

Esistono “ tendenze” :

la scelta del intervento nel ambito della chirurgia dell obesita, e arbitraria

(Necessita di guidelines )

VANTAGGI DELLA TECNICA

Riduzione dela capacita gastrica senza perdita funzionale

Assenza di dumping a causa della preservazione pylorica

Meccanismo “ ormonale”

DIFETTI

Rischi legati alla linea di sutura

Irreversibilita

Laparoscopic sleeve gastrectomy. A bariatric procedure with multiple indications.

Baltasar A: Cir Esp 2006 May;79 (5): 289-92.

30 patienti

63,1 % BMI (76 % nei vari sottogruppi nei due anni)

“Reduction of the ghrelin – production stomach mass may account for its sureriority to other gasric restrictive procedures…long – term studies are necessary to see if it is a durable procedure.”

Gumbs AA, Gagner M. Sleeve gastrectomy for morbid obesity

Obes.Surg 2007 Jul;17(7):962-9

RISULTATI I

A prospective multicenter study of 163 sleeve gastrectomies: results at 1 and 2 years.

Nocca D et al Obes Surg May2008; 18(5):560-5

EWL

48,9% 6 mesi 59,45% 1 anno

62,02% 18 mesi 61,5% 2 anni

RISULTATI II

Results of laparoscopic sleeve gastrectomy: a prospective study in 135 patients with morbid obesity.

Fuks D et al. Surgery 2009 Jan; 145(1) 106-13

EWL

38,6 6 mesi 49,4 1 anno

RISULTATI III

Feasibility and technique of laparoscopic conversion of adjustable gastric banding to

sleeve gastrectomy

Dapri G, Cadiere GB, Himpens J. Surg Obes. Relat Dis.2009

EWL

16,7% adizionale34,8 % totale(!!)

Laparoscopic sleeve gastrectomy: does bougie size affect mean %EWL? Short –

term outcomes.

Parikh M, Gagner M e altri. Surg Obes Relat Dis. 2008 Jul-Aug; 4(4):528-33

( 40 F vs 60 F) !!!???

MORBIDITA

Complicanze per operatorie

Complicanze post operatorie precoci

Complicanze tardive

COMPLICANZE PER OPERATORIE

Transezione gastrica

Emorragia

Ischemia splenica

Traumatismo hepatico

MORTALITA

0 – 3,2%

Aggarwal et al. Surgery Obes Rel Dis 3 2007;189-194

COMPLICANZE POST OPERATORIE PRECOCI

Fistola

Emorragia

Ascesso

COMPLICANZE POST OPERATORIE TARDIVE

Riflusso

Stenosi

COMPLICANZE

The First International Consensus Summit for Sleeve Gastrectomy (SG), New York City, October 25-27, 2007

SERIE PERSONALE (SLEEVE)

TECNICA

French position - 45 0 -Trocar ( 4+1)

TECNICA Infiltrazione anestesia locale

Ultracision

32 fr

Echelon 2 verdi 4-6 gold

Tissue thickness of human stomach measured on excised gastric speciments from obese patients

Elariny H, Gonzalez H, Wang B. Surg Technol Int 2005;14:119-24

Buscopan Drenagio

SG

Technical considerations

RISULTATI (SLEEVE)

EVOLUZIONE BMI (SLEEVE)

ΓΡΑΦΗΜΑ ΜΕΣΟΥ ΒΜΙ ΓΙΑ ΤΙΣ 3 ΧΡΟΝΙΚΕΣ ΠΕΡΙΟΔΟΥΣ

05

101520253035404550

TIME0 TIME6 TIME12

ΜΕΤΡΗΣΗ ΣΕ ΧΡΟΝΟ 0,6 ΜΗΝΕΣ,1 ΕΤΟΣ

ΜΕ

Η Τ

ΙΜΗ

EVOLUZIONE EWL (SLEEVE)

ΓΡΑΦΗΜΑ ΜΕΣΟΥ EWL (%) ΓΙΑ ΤΙΣ 2 ΧΡΟΝΙΚΕΣ ΠΕΡΙΟΔΟΥΣ

0

10

20

30

40

50

60

70

80

90

TIME6 TIME12

ΜΕ

ΣΗ Τ

ΙΜΗ

(%

)

COMPLICANZE I (SLEEVE)

COMPLICANZE II (SLEEVE)

1 anno

GERD = 11%

The mechanism of weight loss and resultant comorbidity improvement seen after sleeve gastrectomy may be related to gastric restriction or neurohumoral changes due to the gastric resection, or some other unidentified factor(s)

Published complication rates range from 0% to 24%, with an overall reported mortality rate of 0.39% Sleeve gastrectomy is probably at least as effective and durable as adjustable gastric banding at 1 and 3 years after surgery Long-term (5 yr) weight loss and comorbidity resolution data for sleeve gastrectomy have not been reported at this time

SG-1

SG-2

Weight regain or a desire for further weight loss in a super-super-obese patient may require the procedure to be revised to a gastric bypass or BPD with duodenal switch.

Sleeve gastrectomy appears to be a technically easier and/or faster laparoscopic procedure than Roux-en-Y GB or malabsorptive procedures in complex or high-risk patients, including the super-super-obese patient (BMI 60 kg/m2)

Sufficient as a “stand alone” procedure ?

From a technical standpoint, there appears to be no consensus regarding the optimal dilator size that should be used to create the lesser curve conduit (32F-60F !!!)

Complications and outcome of SG

Position Statement ASMBS 2007, Surgery for Obesity and Related Diseases 2007;3:573-6 `

AGB vs SG

Kueper M A et al. World J Surg 2008;32:1462-5

AGB vs SG

Kueper M A et al. World J Surg 2008;32:1462-5

AGB vs SG

Wong S KH et al. Hong Kong Med J 2009; 15:100-9

AGB vs SG

Wong S KH et al. Hong Kong Med J 2009; 15:100-9

In a randomized study comparing gastricbanding with sleeve gastrectomy (n = 80), was

found that the median percentage of excess weight loss at 3 years was 48% for gastric banding and 66% for sleeve gastrectomy

Himpens J et al. Obes Surg 2006;16:1450-6

AGB vs SG