Gastric bypass vs. Sleeve gastrectomy

Transcription

1 Gastric bypass vs. Sleeve gastrectomy SLEEVEPASS-study Sleeve gastrectomy Paulina Salminen, M.D., PhD Turku University Hospital Department of Surgery Stockholms Obesitasdagar

2 Swedish Obese Subjects SOS Percent weight change over 15 years Weight change, % Control Banding VBG -30 Gastric bypass Years of follow up Sjöström L et al. N Engl J Med 2007; 357:

3 Bariatric surgery in Finland : 99 operations 2007: 154 operations 2008: 430 operations RYGB 270, SG 150, LGB < : 666 operations RYGB 472, SG 187, LGB : 769 operations 2011: 1056 operations RYGB 919, SG 134, LGB 2, DS registered association FOTEG (Finnish( Obesity Treatment Expert Group)

4 Long-term PROS for sleeve gastrectomy NO internal hernias NO bowel obstruction NO malabsorption NO excluded segments An intact gi-tract

5 SLEEVEPASS studygroup Turku University Hospital Paulina Salminen, Mika Helmiö, Jari Ovaska Vaasa Central Hospital Pipsa Peromaa, Mikael Victorzon Peijas Hospital, Helsinki Anne Juuti, Marja Leivonen

6 Study hypothesis As sleeve gastrectomy is less traumatic, easier and faster to perform compared with gastric bypass, LSG could become the procedure of choice to treat morbid obesity if the long-term results of weight loss and resolution of comorbidities are comparable with laparoscopic gastric bypass. NCT Patient enrollment and operative treatment April 2008 June 2010

7 Inclusion criteria BMI 40 or BMI 35 and a significant co-morbidity associated with morbid obesity Age years Previous successfully instituted and supervised but failed adequate diet and exercise program

8 Exclusion criteria BMI > 60 Age > 60 or < 18 Significant psychiatric disorder Severe eating disorder Active alcohol / substance abuse Active gastric ulcer disease Difficult GERD with a large hiatal hernia Previous bariatric surgery

9 Preoperative evaluation Multidisciplinary evaluation Upper gastrointestinal endoscopy Small hiatal hernia: SLEEVE 19.8 %, BYPASS 21.8 % Helicobacter pylori: SLEEVE 18.6 %, BYPASS 17.1 % Ultrasound examination Gallstones: SLEEVE 22.9 %, BYPASS 25.3 %

10 Operative technique / RYGB A small gastric pouch (20 40 ml) Biliopancreatic limb cm Antecolic gastrojejunostomy Linear (45 mm) n = 56 Circular (OrVil 25 mm) n = 59 Alimentary limb 150 cm Jejunojejunostomy Closure: running suture / totally stapled technique NO routine closure of mesenteric defects Methylene blue test for gastrojejunostomy

11 Operative technique / SG Calibration bougie Fr 1st resection 4 6 cm proximal to the pylorus 2 x green-load firings, ~ 4 x blue-load firings Resection followed by mobilization of the stomach Methylene blue test 2/3 centers

12 Patient demographics (p = ns) Age: median 49 years (range years) 70 %, 30 % Preoperative BMI: median 44.6 kg/m² (range kg/m²)

13 SLEEVEPASS CONSORT 30-day flowchart

14 SLEEVEPASS: Operation time and hospitalization SLEEVE BYPASS p-value Mean operation time (min) 66 min ( min) 94 min ( min) < Mean hospitalization duration (days) 4.5 days 4.9 days

15 SLEEVEPASS: Complications SG vs. RYGB 30-day morbidity Minor = all other postoperative complications SG 7.4 % vs. RYGB % (p = 0.023) Major = reoperation, hospital stay > 7 days, need for blood transfusions > 4 units SG 5.8 % vs. RYGB 9.4 % (p = 0.292)

16 SLEEVEPASS: Complications SG vs. RYGB 30-day morbidity Minor = all other postoperative complications SG 7.4 % vs. RYGB % (p = 0.023) Major = reoperation, hospital stay > 7 days, need for blood transfusions > 4 units SG 5.8 % vs. RYGB 9.4 % (p = 0.292)

17 SLEEVEPASS: Complications SG vs. RYGB 30-day morbidity Mortality 0 % Overall morbidity SG 16.2 % vs RYGB 26.5 % (p = 0.010)

18 SLEEVEPASS SG Reoperations, p = ns SLEEVE Five reoperations (4.1 %) on three patients Patient 1 Arterial bleeding laparotomy on the operation day Patient 2 Bleeding re-laparoscopy on the 1st postop. day Patient 3 Bleeding re-laparoscopy on the 1st postop. day Small bowel perforation re-laparoscopy at two weeks laparotomy + bowel resection

19 SLEEVEPASS RYGB Reoperations BYPASS Six reoperations (5.1 %) on four patients Patient 1 Bleeding re-laparoscopy on the operation day Patient 2 Bleeding re-laparoscopy on the 1st postop. day Patient 3 Torsion of the enteroanastomosis laparotomy on the 5th postop. day Patient 4 Bleeding re-laparoscopy on the 7th postop. day laparotomy on the 14th postop. day angiography and coiling of the pseudoaneurysm on the 17th postop.day

20 123 papers, patients

21 12 months mean EWL SG 56 % vs. RYGB 68 % (p < 0.01) 17 SG studies, 12 RYGB studies 24 months mean EWL SG 61 % vs. RYGB 70 % (p = 0.09) 7 SG studies, 10 RYGB studies

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23 5-year follow-up:64 patients / patients (0,5 %)

24 11/ / 2002, n = 53 6-year follow-up stand-alone SG 30 / 41 patients, telephone questionnaire EWL 53 % vs. 78 % at 3-year follow-up New GERD complaints in 21 % 11 patients underwent DS EWL 57 % vs. 73 % at 3-year follow-up Ann Surg 2010;252:

25 34-Fr bougie to guide the gastric division vs. to calibrate a more narrow sleeve? Follow-up visits? Post-SG GERD?

26 Group A: no calibration Group B: 44 Fr Group C: 32 Fr B & C (!) higher %EWL

27 n = 26 5-year mean EWL 55 % 15 % converted to RYGB Weight loss failure n = 3 Severe reflux n = 1 31 % (n = 8) required daily PPI

28 Mean preoperative BMI 39.3 kg/m² At median follow-up of ~ 4 years mean EWL 72.3 % (n = 83 / 102 patients) vs. EWL 55.9 % at 6-year follow-up (23 patients)

29 Mean preoperative BMI 36.9 kg/m², mean age 37 years n = 773 EWL at 3-year follow-up 84.5 % Leakage rate 0.7 % Stenosis 0.1 % GERD 0.7 %

30 Collective experience of > SG Achieving consensus 70 % agreement No consensus < 70 % agreement

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34 SG technique consensus Rosenthal et al. Soard 2012;8: 8-19 Bougie! Antrum / green loads Transsection 2 6 cm from pylorus Last firing AWAY from the GE junction! Complete mobilization of the fundus The use of staple line reinforcement

35 SG and GERD Rosenthal et al. Soard 2012;8: 8-19 Preoperative evaluation Hiatoplasty and SG?

36 RYGB vs. SG: Weight regain? SOS Percent weight change over 15 years Weight change, % Control Banding VBG -30 Gastric bypass Years of follow up Sjöström L et al. N Engl J Med 2007; 357: Himpens et al. Ann Surg 2010;252:

37 In conclusion SG 2012 SG a valid stand-alone procedure Technical aspects Long-term follow-up is required Patient selection GERD? (postoperative incidence 0.7 % 31 %)

38 In conclusion RCT: SLEEVEPASS At 30-day analysis SG is associated with a shorter operation time and fewer early complications At 6-month follow-up SG and RYGB have similar %EWL, resolution of co-morbidities and morbidity rate Long-term follow-up is required to determine the effect of sleeve gastrectomy on weight loss and resolution of obesity related co-morbidities compared with RYGB SLEEVEPASS-trial follow-up will be continued up to 15 years

39 Thank You!