Disclosure. consultant to Ethicon Endosurgery. case mix disclosure. LRYGB sleeve BPD revisions OAGB ( minibp ), SADI: 0% 19% 55% 23%

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2 Disclosure consultant to Ethicon Endosurgery case mix disclosure 3% 19% 23% 55% LRYGB sleeve BPD revisions OAGB ( minibp ), SADI: 0%

3 Disclosure consultant to Ethicon Endosurgery case mix disclosure 3% 19% 23% 55% LRYGB sleeve BPD revisions OAGB ( minibp ), SADI: 0%

4 % procedures BACKGROUND procedures worldwide/europe world: N= europe: N= Gastric Band Gastric Bypass Sleeve Gastrectomy BPD/DS OAGB Angrisani, Obes Surg

5 OBJECTIVE SM-BOSS Is sleeve as effective and safe as bypass at 5 years

6 METHODS SM-BOSS randomized clinical trial multicentre: - Claraspital Basel, Bern, Zürich, St.Gallen endpoints: - primary: weight loss (excess BMI loss) at 5 y - secondary: reduction of co-morbidity support: QoL safety metabolic effects (gut hormones, adipokines, bile acids, ) (Peterli, Ann Surg 09, Obes Surg 12, Wölnerhanssen SOARD 11, Steiner Obesity 13) - Swiss National Science Foundation - Ethicon Endosurgery, USA

7 Patients SM-BOSS patients evaluated for surgery 1/ /2011 N = 3971 randomized during outpatient visit N = 225 excluded: severe GERD, big hiatal hernia adhesions small bowel necessity to endoscopically examine duodenum Crohn s disease denied participation LSG n = 112 LRYGB n = 113 excluded: sleeve n = 107 bypass n = 110 crossover LRYGB LSG (n=1) operation > 1/2012 (n=7) dropouts (FU rate = 95%): sleeve n = 101 5y bypass n = 104 LRYGB ( =2, abroad 2, lost=1) LSG (abroad=3, lost=3)

8 Operation Techniques SM-BOSS sleeve: - 35 F bougie - 3-6cm prepyloric to angle of His - suturing of stapler line bypass: - 150cm alimentary limb, antecolic - 50cm bilio-pancreatic limb - circular or linear technique - defects closed in circular, not in linear technique

9 SM-BOSS previous results early (1 year): sleeve faster, (safer); equal weight loss 3 years: equal weight loss, complications, QoL, co-morbitiy except GERD, dyslipedemia: bypass better

10 5-YEAR RESULTS Weight loss (BMI) SM-BOSS N = 217 (FU rate 95%) 70 mean Body Mass Index, kg/m kg kg 0 Peterli, JAMA Years Post-Surgery = 3.6 kg

11 5-YEAR RESULTS Excess BMI loss SM-BOSS Peterli, JAMA 2018

12 Weight loss Literature RCT Author Journal Year N FU years FU-rate % reported as Mean weight loss p sleeve bypass sleeve bypass Karamanakos Ann Surg % EWL Kehagias Obes Surg % EWL n.s. Schauer (Stampede) NEJM Δ Baseline [%] NEJM % EBMIL Zang Obes Surg % EWL Ignat BJS % EWL Salminen (Sleevepass) Peterli (SM-BOSS) JAMA % EWL n.s. Ann Surg % EBMIL n.s. JAMA % EBMIL n.s.

13 EBMIL (%) Year Long-term Weight loss sleeve durable? N = 167 FU: min 5y (93%) -10 y (74%) Pat # Pat # 1-86 Author N FU (years) FU (rate, %) % EWL Rawlins Prager Himpens Gadiot (?) 54 Kowalewski years after LSG Claraspital Kraljevic & Peterli, submitted 13

14 Long-term Weight loss durable SOS trial bypass Utah, USA: 12 y post bypass, 97% FU rate Sjöström, JAMA 2014 Adams, NEJM

15 Weight loss long term (literature) Osland, Surg Laparosc Endosc Percutan Tech 2017; Buchwald, Am J Med 2009

16 5-YEAR RESULTS Diabetes SM-BOSS n=26 n=28 n.s. 0% 50% 100% remission improved unchanged worsened 0% 50% 100% remission improved unchanged worsened Gluc 6.4 ± ±0.31 (p=0.21) HbA1c 6.2 ± ±0.16 (p=0.09) Peterli, JAMA 2018

17 Diabetes Literature Schauer, NEJM 2017 & Diabetes care 2016; Müller, Ann Surg 2015, Buchwald, Am J Med 2009

18 5-YEAR RESULTS Dyslipidaemia SM-BOSS n=68 n=53 p=0.09* 0% 50% 100% remission improved unchanged worsened 0% 50% 100% remission improved unchanged worsened LDL 3.0 ± ±0.08 (p=0.008) Chol/HDL q 3.3 ± ±0.09 (p=0.02) Peterli, JAMA 2018 * after adjustment for multiple comparisons

19 5-YEAR RESULTS GERD SM-BOSS n=44 n=48 p=0.002/0.006* 0% 50% 100% remission improved unchanged worsened 0% 50% 100% remission improved unchanged worsened new onset GERD: 31.6% vs 10.7% (p=0.01) Peterli, JAMA 2018 * after adjustment for multiple comparisons

20 COMPLICATIONS up to 3 years SM-BOSS = Peterli, Ann Surg 2017

21 COMPLICATIONS up to 5 years SM-BOSS Complication necessitating reoperation/endoscopic intervention sleeve n = 101 bypass n = 104 p GERD 9 LRYGB insufficient weight loss 3 lap. BPD-DS 2 LRYGB 1 banded bypass 1 pouch resizing 0.12 small bowel obstruction internal hernia severe dumping 0 1 banded bypass 1 Apollo 1 reversion 0.25 incisional hernia laparoscopy for gastroscopy NA 1 total >30d all reoperations/interventions (early* & late) Peterli, JAMA 2018 * Peterli, Ann Surg

22 Surgery for GERD & Stenosis & HH after sleeve Author Year N FU years reop % type % t postop m Prager Himpens bypass 95 BPD-DS 5 bypass 50 hiatoplasty Gadiot (15) bypass 100 Claraspital bypass 82 hiatoplasty Barrett s oesophagus - 17% in asymptomatic pts >4y postop * - 12% 5 y postop # * Genco, SOARD 2017; # Felsenreich & Prager, Obes Surg

23 Surgery for internal hernia after bypass Aghajani & Gislason, Surg Endosc 2017 Stenberg, BJS

24 SUMMARY SM-BOSS sleeve vs bypass at 5 years (95% of 217 pts): - weight loss not sign. different* (61 vs 68% EBMIL) - co-morbidities: - T2DM: remission: 62 vs 68% (underpowered) - dyslipidaemia: bypass ±better (p=0.09*) - GERD: bypass better (remission 25 vs 60.4%; de novo: 31.6 vs 10.7%) - QoL improved markedly with both procedures - number of complications necessitating reoperation/intervention: vs 22.1% Peterli et al., JAMA 2018 *after adjustment for multiple comparisons

25 CONCLUSION 1 SM-BOSS rapid switch from bypass to sleeve misadventure - but: weight loss with longer FU? metabolic effect equal? safety: - sleeve: GERD, Barrett - bypass: internal hernia, severe dumping

26 CONCLUSION 2 good candidate for sleeve: - very high BMI - necessity of endoscopic access - extensive previous surgery (expected adhesions), big hernias - Crohn s disease - professional driver (fear of dumping) - elderly patient good candidate for bypass: - GERD, large hiatal hernia - esophageal motility disorder - T2DM, dyslipidemia patient selection & information important