Sleeve Gastrectomy: Harmful. John C. Eun, PGY-5 General Surgery Grand Rounds University of Colorado Denver 11/22/10
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1 Sleeve Gastrectomy: Harmful John C. Eun, PGY-5 General Surgery Grand Rounds University of Colorado Denver 11/22/10
2 Background Obesity: Body Mass Index >30 Risk factor for CAD, DM, Cancers
3 Obesity Trends* Among U.S. Adults BRFSS, 1989 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14%
4 Obesity Trends* Among U.S. Adults BRFSS, 1990 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14%
5 Obesity Trends* Among U.S. Adults BRFSS, 1991 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19%
6 Obesity Trends* Among U.S. Adults BRFSS, 1992 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19%
7 Obesity Trends* Among U.S. Adults BRFSS, 1993 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19%
8 Obesity Trends* Among U.S. Adults BRFSS, 1994 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19%
9 Obesity Trends* Among U.S. Adults BRFSS, 1996 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19%
10 Obesity Trends* Among U.S. Adults BRFSS, 1995 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19%
11 Obesity Trends* Among U.S. Adults BRFSS, 1997 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20%
12 Obesity Trends* Among U.S. Adults BRFSS, 1998 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20%
13 Obesity Trends* Among U.S. Adults BRFSS, 1999 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20%
14 Obesity Trends* Among U.S. Adults BRFSS, 2000 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20%
15 Obesity Trends* Among U.S. Adults BRFSS, 2001 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20% 24% 25%
16 Obesity Trends* Among U.S. Adults BRFSS, 2002 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20% 24% 25%
17 Obesity Trends* Among U.S. Adults BRFSS, 2003 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20% 24% 25%
18 Obesity Trends* Among U.S. Adults BRFSS, 2004 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20% 24% 25%
19 Obesity Trends* Among U.S. Adults BRFSS, 2005 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30%
20 Obesity Trends* Among U.S. Adults BRFSS, 2006 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30%
21 Obesity Trends* Among U.S. Adults BRFSS, 2007 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30%
22 Obesity Trends* Among U.S. Adults BRFSS, 2008 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30%
23 Obesity Trends* Among U.S. Adults BRFSS, 2009 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30%
24 Bariatric Surgery Due to the limited success of conservative therapy (exercise, diet, medical ) Bariatric procedures have been gaining momentum. BMI 40 BMI 35 with comorbidities Spiegel, Skawran. J Gastrointest Surg 2010.
25 Malabsorptive Procedures Mun et al. Gastroenterology 2001.
26 Restrictive Procedures Mun et al. Gastroenterology 2001.
27 Restrictive and Malabsorptive Mun et al. Gastroenterology 2001.
28 Sleeve Gastrectomy Shi et al. Obes Surg 2010.
29 Sleeve Gastrectomy Longitudinal gastric resection initially developed as a treatment of peptic ulcer disease (1940 s-1990 s). Started as a treatment of bariatric surgery in 1993 P. Marceau modified the BPD with a longitudinal gastrectomy. First used as a initial intervention in high-risk patients. Becoming more popular as a single intervention. Spiegel, Skawran. J Gastrointest Surg 2010.
30 Pros and Cons No anastomosis Maintain continuity of the GI tract and physiological food passage Maintain pylorus No standardization of procedure Type of stapler Number of staple firings Size of resected stomach Size of the calibration bougie Reinforcement of the staple line
31 Bariatric Surgery Buchwald, Oien. Obes Surg 2009.
32 Bariatric Surgery Buchwald, Oien. Obes Surg 2009.
33 Sleeve Gastrectomy Safe? Effective?
34 Retrospective study: 25 hospitals, 62 surgeons 15,275 patients 30-day morbidity
35 Birkmeyer et al. JAMA 2010
36 Birkmeyer et al. JAMA 2010
37 Literature review for LSG studies: 1 RCT, 6 retrospective, 8 prospective
38 Shi, et al. Obes Surg 2010.
39 Shi, et al. Obes Surg 2010.
40 RCT, single center: Jan 1-Dec GB, 40 SG
41 Surgery Postoperative Complication Number Banding none none N/A Sleeve Gastrectomy Intraperitoneal bleeding Treatment 1 Re-laparoscopy Gastric Ischemia 1 Total Gastrectomy the severity of complications appear higher in sleeve gastrectomy Himpens, etl al. Obesity Surgery 2006
42 Prospective, single institution study 261 patients Chronicles the early experiences
43 The actual long-term efficacy of the procedure remains to be confirmed. Morbidity rates may prove higher than expected especially during the learning curve Menenakos et al. Obes Surg 2010.
44 Surg Endosc 2010 Retrospective review: patients 3 operating surgeons 1 bariatric surgeon 2 laparoscopic surgeons
45 Daskalakis et all.surg Endoc 2010.
46 Review article examining the leak rate of 11 studies Examined the utility of oversewing of the staple line There is no reason to believe, at this point, that reduction in leak rates occur because reinforcement is used
47
48 16 pts each arm Monitored weight loss at 1,2, 6, 12 months post op
49 P=0.04 P=0.05
50 Summary Higher complication rate that gastric banding. Bleeding Leak Lack of long term data on outcomes
51 Conclusion Not the best surgery for high risk patients Not the best surgery for known long-term weight loss/co-morbidity resolution in patients who can undergo an operation.
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