LONG TERM OUTCOMES OF SLEEVE GASTRECTOMY (LSG) Jacques Himpens, Gustavo Arman The European School of Laparoscopic Surgery Brussels Belgium

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1 LONG TERM OUTCOMES OF SLEEVE GASTRECTOMY (LSG) Jacques Himpens, Gustavo Arman The European School of Laparoscopic Surgery Brussels Belgium

2 DISCLOSURE DR HIMPENS IS A CONSULTANT WITH ETHICON ENDOSURGERY AND WITH MEDTRONIC DR ARMAN HAS NOTHING TO DISCLOSE THERE IS NO CONFLICT OF INTEREST WITH THE MATERIAL PRESENTED HERE

3 CASE MIX SLIDE Sleeve OAGB RYGB DS/SADI Redo 26%

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5 Angrisani L et al. Obes Surg 2018

6 Esteban Varela J, Nguyen NT. Laparoscopic sleeve gastrectomy leads the U.S. utilization of bariatric surgery at academic medical centers. Surg Obes Relat Dis Feb 12.

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8 LSG intended as sole operation N=110 consecutive patients Evaluation 2015 (Follow-up yrs) 63 patients evaluated (35 lost, 2 dead from unrelated causes)

9 SURGICAL TECHNIQUE In brief, the linear gastrectomy was started some 5 6 cm proximal to the pylorus and was performed using a 34F bougie as a guide inside the stomach lumen. The technique thus did not involve extensive dissection of the hiatus

10 The cohort of patients not available for follow-up was statistically similar to the patients available in terms of age, gender, weight and BMI

11 For the 16 patients with new anatomy the revision operation was performed 31 months (IQR 65) after LSG Arman et al. SOARD 2016

12 Arman et al. SOARD 2016

13 N=6 N=3 N=10 N=49 no conversion DS RYGB Re-sleeve N=63 Arman et al. SOARD 2016

14 1.- WEIGHT OUTCOMES AT > 11 YEARS

15 No Conversion (N= 47) EBMIL 62.5% TWL 21% N=63 Arman et al. SOARD 2016

16 At 11+ years, %EBMIL was 62.5% % TWL 21%

17 RYGB EBMIL 78.8% DS EBMIL 83.5% Re-sleeve N=3 EBMIL 14.7% No Conversion EBMIL 62.5% N=63 Arman et al. SOARD 2016

18 Weight parameters for the 3 groups at the different time points Group A: LSG Group B: Conversion Group A+B: overall Significant weight (re)gain between 3 and 11 years and between 6 and 11 years values ((BMI, %EBMIL and %TWL) for the LSG participants

19 Arman et al. SOARD 2016

20 Arman et al. SOARD 201

21 BMI (kg/m2) LSG + DS/RYGB LSG years Arman et al. SOARD 2016

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23 N=5264 SOARD 2016

24 Shoar et al. SOARD 2016 < 5 years > 5 years

25 Our meta-analysis showed an insignificant weight loss difference in the midterm, but a significantly better weight loss outcome in the longterm with LRYGB than with LSG Shoar et al. SOARD 2016

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27 110 Int J Surg 2014;12 (5): SOARD 2016;12 (9): SOARD2016;12 (10): SOARD 2016;12(4): SOARD2016;12 (9): Obes Surg 2017;27(1):59-63 SOARD 2017;13(7): SOARD 2016;12;12(S1-S32) SOARD 2012;8(6):679-84

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29 N= 2280, including 652 with follow-up >7 years Weight recidivism 27.8% (14-37%) Revision rate 19.9% Revision rate for weight regain 13.1% Revision rate for GERD 2.9% Clapp B et al.

30 Clapp B et al.

31 Weight loss LSG=RYGB RYGB>LSG Leyba J Peterl R Vidal P Lakdawala MA Lim DM Zhang C Maciejewski ML Zhay Y El Chaar M Thereaux J (BMI>50) Celio AC (BMI>50) Leyba J et al. Obes Surg 2011;21(2):212 6; Obes Surg 2014;24(12): Peterli R et al. Ann Surg 2013; 258: Vidal P et al. Obes Surg 2013; 23: Lakdawala MA et al. Obes Surg 2010; 20: 1 6 Lim DM et al. SOARD 2014; 10: Zhang C et al. Obes Surg 2014; 24: Maciejewski ML et al. JAMA Surg 2016; 151: El Chaar M et al. Obes Surg 2015; 25: Thereaux J et al. SOARD 2015; 11: Celio A et al. Surg Endosc 2017; 31:

32 2.-Comorbidities at 11+ years

33 N at time of LSG N with sleeve anatomy at F-up N with sleeve suffering from comorbidity at F-up Remission Rate (%) T2DM Dyslipidemia Sleep Apnea S Art Hypertension

34 LSG and comorbidities (T2DM) T2DM remission Meta-analyses LSG=RYGB Zhang C Yip S RYGB>LSG LI JF Zhang C et al.obes Surg 2014; 24: Yip S et al. Obes Surg 2013; 23: LI JF et al. Can J Surg 2013; 56: E158 E164 Li JF et al. Surg Laparosc Endosc Percutan Tech 2014;24:1-11

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36 Modified from Peterli et al. Outcomes at 3 years for LSG and LRYGB in terms of remission or improvement for 3 metabolic conditions AHT, Dyslipidemia and T2DM CONCLUSION: no significant difference in terms of T2DM or AHT remission/improvement In terms of dyslipidemia LRYGB has a better outcome (however study underpowered for T2DM remission)

37 3.- GERD at 11+ years

38 Arman et al. SOARD 2016 Fig. 5 2 patients treated by RYGB for GERD (1 de novo) Surgery for Obesity and Related Diseases DOI: ( /j.soard ) Copyright 2016 American Society for Bariatric Surgery Terms and Conditions

39 Of the 7 preoperatively GERD-positive patients, none improved; 6 continued PPI intake and 1 required conversion to RYGB primarily because of GERD (remission rate = 0%). Of the 56 preoperatively GERD negative patients, 14 did not keep the simple sleeve anatomy because of weight issues not related to GERD; in the remaining 42 individuals, 9 (21.4% of the total of followed patients) developed de novo GERD, which required conversion to RYGB in 1. Arman et al. SOARD 2016

40 N=53 37 pts not converted 10 (38%) GERD (PPI)

41 Gastroscopies revealed de novo hiatal hernias in 45% of the patients and Barrett s metaplasia in 15%. Felsenreich et al. Obes Surg 2017

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43 LSG and GERD GERD worsened Unsure GERD improved Himpens J Oor J Rawlins L Hutter MM DuPree C Casella J Keren D Leivonen M Chiu S Arman G Barr A Himpens J et al. Ann Surg 2010;252 (2): Hutter MM et al. Ann Surg 2011;254 (3): Keren D et al. Obes Surg 2011;21(12): Leivonen M et al. Obes Surg 2011:21(8): Chiu S et al. SOARD 2011;7(4): Arman G et al. Surg Obes Relat Dis Dec;12(10): Oor J et al. Am J Surg 2016;211(1): DuPree C et al. JAMA Surg 2014;149(4): Rawlins L et al. SOARD 2013;9(1):21-25 Casella J et al. SOARD 2016;12(4): Barr A et al. Surg Endosc 2017;31(1):410-5

44 C l a p p B e t a l.

45 4.- PATIENT SATISFACTION

46 Overall satisfaction score (i.e., for the entire cohort) was 8 (IQR 2) 83% of the patients had a score > 7 (pleased or extremely pleased). for patients with preserved sleeve anatomy the final score was 8 (IQR 2), for patients with different anatomy the mean satisfaction score had gone up from (1 10), before the revision, to the current 8 (IQR 2) (P <.011) Arman G, et al. SOARD 20 16

47 CONCLUSIONS At 11+ years, LSG alone produces an EWL of some 62% When needed a 2nd stage procedure (RYGB or DS) provides an EWL > 80% after 11+ years At 11+ years after LSG GERD is a frequent (21%) problem GERD issue depending on technique? Long-term patient satisfaction after LSG is good provided 2nd stage surgery is offered in timely fashion