Technique. Matthew Bettendorf, MD Essentia Health Duluth Clinic. Laparoscopic approach One 12mm port, Four 5mm ports

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1 Matthew Bettendorf, MD Essentia Health Duluth Clinic Technique Laparoscopic approach One 12mm port, Four 5mm ports Single staple line with no anastamosis 85% gastrectomy Goal to remove <500 ml Remaining volume ml 60 minute operative time

2 Indications BMI > 60 1st portion of staged procedure Reduce risk BPD/DS or RYGB as second stage Technical inability to complete RYGB Inflammatory bowel disease Indications Necessity to continue specific medications Immunosuppressants Anti inflammatory agents Patient refusal of Anatomic rearrangement of intestinal anatomy Implanted device Indications Many lose adequate weight with satisfactory comorbidity resolution, and forego second stage. Patient selection criteria is expanding Increasingly favored for BMI Has become primary weight loss procedure Procedure is gaining popularity

3 History The Magenstrasse & Mill Operation for Morbid Obesity Similar procedure to Sleeve gastrectomy Gastroplasty without partial gastrectomy Mean EWL = 60% Complications: 4% Abscess, bleeding, splenectomy Sleeve Results (2003 to 2009) 36 studies 1795 patients Followup: 6 months to 5 years Preop BMI: Postop BMI: %EWL 33 85% Complication rate: 0 24% Literature Complications Leak 2.2% Bleeding 1.2% Stricture 0.6% Abscess Acute cholecystitis Ulcer Micronutrient deficiency

4 Literature A Prospective Randomized Study Between LAGB & LSG: Results after 1 and 3 years Obesity Surgery, 2006; 16: patients EWL at 1 year: 41.4 vs EWL at 3 years: 48% vs. 66% Literature Weight loss, appetite suppression, and changes in fasting and postprandial ghrelin and peptide YY levels after Roux en Y gastric bypass and sleeve gastrectomy: a prospective, double blind study Ann Surg, 2008; 247: patients in each group LSG RYGB 70% EWL at 1 year 61% EWL at 1 year Literature LSG as an initial weight loss procedure for highrisk patients with morbid obesity Surg Endosc, 2006; 20: consecutive LSG 36 completed second stage LRYGB EWL one year 46% Complications: 14% Leak, PE, Resp failure, GOO, Renal insuf

5 Literature Sleeve Gastrectomy in the High Risk Patient 821 patients Complications: 0 24% Leak 8/ % Bleeding 11/ % Stricture 6/ % Mortality 2/ % Comorbidity Resolution Condition Resolved Improved Sleep apnea 80% 7% Peripheral edema 91% 3% HTN 78% 7% DJD 85% 6% Type II DM 81% 11% Low back pain 44% 10% GERD 70% 8% Hypertriglyceridemia 73% 5% Depression 67% 9% Comorbidity Resolution after SG Type II Diabetes Early resolution is better with gastric bypass Results match at one year Improvement of insulin action occurs rapidly and independently of EWL Hormonal mechanism contributes to changes in insulin resistance following SG Resolution as early as 4 months post op

6 ASMBS Position Statement Quality and Quantity of Evidence Fair to Good Complications Morbidity 0 24% Mortality 5/2750 (0.19%) Efficacy 33 85% EWL Co morbidity reduction comparable to VBG/LAGB Durability 3 5 year data comparable to VBG/LAGB ASMBS Position Statement A deficiency of long term follow up data remains in the published surgical reports to confirm the effectiveness of SG as a stand alone intervention at > 5 years. Such long term data might or might not ultimately confirm that the procedure should remain in the category of a staged treatment intervention. ASMBS Position Statement an option for carefully selected patients undergoing bariatric surgical treatment, particularly those who are high risk or supersuper obese, and that the concept of staged bariatric surgery may have value as a risk reduction strategy in high risk patient populations. Emphasize the importance of informed consent

7 How does it work? Restriction / Energy intake reduction Intestinal Distension Neurohumoral changes Gastric resection Gastric emptying Decreased hunger Increased postprandial satiety sensation Subsequent reduction of food intake. Function Restriction / Energy intake reduction ml pouch Gastric emptying rate Data not clear, favors normal transit time Pyloric preservation Function Intestinal distension Absence of receptive relaxation Distension of antrum Alterations in contractile activity in proximal stomach Gastric pacer affected? Degree of processing prior to duodenal delivery Changes in entero hypothalamic axis stimulated by distension

8 Function Biochemical Ghrelin Resistin GLP 1 PYY GIP Leptin Adiponectin Function Biochemical Procedures that provoke these work better than those that cannot Discovered after the development of current procedures This may eventually lead to alterations in current operations Ghrelin Mainly produced by neuroendocrine cells primarily located in the gastric fundus Orexigenic Acts as major anabolic hormone Strong GH releasing action on somatotroph cells within adenohypophysis of pituitary

9 Ghrelin May have a role in short & long term energy balance Suppresses insulin sensitizing hormone adiponectin Blocks hepatic insulin signaling Inhibits insulin secretion Decreased levels after SG within 1 month GLP 1 Produced by L cells Stimulated by nutrients reaching ileum Stimulates insulin biosynthesis in pancreatic β cells Slows intestinal transit Slows gastric emptying Promotes central satiety Rapid secretion during meal with T1/2 of 3 7 minutes GLP 1 Attenuated in obese patients Increases after SG Restores insulin sensitivity Inhibits glucagon secretion which decreases hepatic glucose production

10 PYY Produced by L cells Stimulated by nutrients reaching ileum Post prandial release Slows intestinal transit Slows gastric emptying Promotes central satiety Attenuated in obese patients Increases after SG Inflammation Obesity is a low grade chronic inflammatory condition Increased adipose tissue secretion of proinflammatory cytokines IL 6 TNFα Central role in atherogenesis Plaque progression and related complications Inflammation CRP Protein synthesized by liver in response to IL 6 and other pro inflammatory cytokines Increased levels: Increased incidence of coronary heart disease Increased mortality rates Linked to development of Type II DM After bariatric surgery there is consistent reduction in CRP levels within 6 months Reduced risk of cardiovascular diseases

11 Nutritional Deficiencies Vitamin B12 Folic Acid Vitamin D Iron Zinc Nutritional Deficiencies Obesity Surgery, 2010, 20: Nutritional deficiency in SG vs. RYGB F/U 24.4 months, 100% N= RYGB, 50 Sleeve 57% had > 1 deficiency 23% had D deficiency RYGB had significantly higher deficiencies in B12, D, secondary hyperparathyroidism Nutritional Deficiencies Iron deficiency (5%) Reduced gastric acid B12 deficiency (25%) Reduced intrinsic factor Folate deficiency (10%) Anemia Follow B12 and Folate Iron supplement not necessary in non anemic patients Multivitamin, annual labs

12 Sleeve Gastrectomy Advantages Reduced technical challenges Reduced major compications Low mortality Short operating time Minimal nutritional complications General structure of organ preserved No mechanical obstacles Sleeve Gastrectomy Advantages Rapid weight loss, similar to gastric bypass Few compliance issues (adjustments) No foreign body or device complications Second stage simplified No marginal ulcers Can take NSAIDS, ASA No vomiting, diarrhea, flatulence Sleeve Gastrectomy Disadvantages Potential for leaks (less than bypass) Not reversible Gastroesophageal reflux Micronutrient deficiencies Long term results pending

13 Failure Inappropriate Diet Inadequate Exercise Pouch dilation Pouch size may increase, but EWL and BMI remain stable out to 2 years Other considerations Adolescent patients Growth hormone Pregnancy No difference in birthweight across bariatric procedures High pregnancy rate (12.5%) in adolescent populations Option for revisional surgery Feasible and safe for failed AGB/VBG 43% 13 months The ideal bariatric operation: Low mortality Low morbidity Minimally invasive Excellent comorbidity resolution Technically straight forward Limited need for follow up Few late complications Avoid induced nutritional deficiencies

14 Conclusion Sleeve gastrectomy is a safe and effective means for weight loss and comorbidity resolution. Long term data is accumulating Procedure is gaining popularity & selection criteria is expanding Appropriate patient selection is necessary. Sleeve gastrectomy with or without additional modifications may become the gold standard for bariatric surgery.