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

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

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

CASE MIX SLIDE 2017-2018 Sleeve OAGB RYGB DS/SADI Redo 26%

Angrisani L et al. Obes Surg 2018

Esteban Varela J, Nguyen NT. Laparoscopic sleeve gastrectomy leads the U.S. utilization of bariatric surgery at academic medical centers. Surg Obes Relat Dis. 2015 Feb 12.

2001 2003 LSG intended as sole operation N=110 consecutive patients Evaluation 2015 (Follow-up 11.7 + 4 yrs) 63 patients evaluated (35 lost, 2 dead from unrelated causes)

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

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

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

Arman et al. SOARD 2016

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

1.- WEIGHT OUTCOMES AT > 11 YEARS

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

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

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

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

Arman et al. SOARD 2016

Arman et al. SOARD 201

BMI (kg/m2) 45 40 35 30 25 20 15 10 5 0 LSG + DS/RYGB LSG 1 2 3 4 5 6 7 8 0 1 2 3 4 5 6 7 8 9 10 11 years Arman et al. SOARD 2016

N=5264 SOARD 2016

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

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

110 Int J Surg 2014;12 (5):504 8. SOARD 2016;12 (9):1689 96. SOARD2016;12 (10):1778 86 SOARD 2016;12(4):757 62.. SOARD2016;12 (9):1655 62. Obes Surg 2017;27(1):59-63 SOARD 2017;13(7):1110-5 SOARD 2016;12;12(S1-S32) SOARD 2012;8(6):679-84

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.

Clapp B et al.

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):2094 8 Peterli R et al. Ann Surg 2013; 258: 690 694 Vidal P et al. Obes Surg 2013; 23: 292 299 Lakdawala MA et al. Obes Surg 2010; 20: 1 6 Lim DM et al. SOARD 2014; 10: 269 276 Zhang C et al. Obes Surg 2014; 24: 1528 1535 Maciejewski ML et al. JAMA Surg 2016; 151: 1046 1055 El Chaar M et al. Obes Surg 2015; 25: 254 262 Thereaux J et al. SOARD 2015; 11: 785 790 Celio A et al. Surg Endosc 2017; 31: 317 323

2.-Comorbidities at 11+ years

N at time of LSG N with sleeve anatomy at F-up N with sleeve suffering from comorbidity at F-up Remission Rate (%) T2DM 3 0 1 0 Dyslipidemia 12 10 6 40 Sleep Apnea S 4 3 2 33 Art Hypertension 12 7 6 14

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: 1528 1535 Yip S et al. Obes Surg 2013; 23: 1994 2003 LI JF et al. Can J Surg 2013; 56: E158 E164 Li JF et al. Surg Laparosc Endosc Percutan Tech 2014;24:1-11

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)

3.- GERD at 11+ years

Arman et al. SOARD 2016 Fig. 5 2 patients treated by RYGB for GERD (1 de novo) Surgery for Obesity and Related Diseases DOI: (10.1016/j.soard.2016.01.013) Copyright 2016 American Society for Bariatric Surgery Terms and Conditions

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

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

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

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):319 24 Hutter MM et al. Ann Surg 2011;254 (3):410 20. Keren D et al. Obes Surg 2011;21(12):1887 93. Leivonen M et al. Obes Surg 2011:21(8):1180-7 Chiu S et al. SOARD 2011;7(4):510 5. Arman G et al. Surg Obes Relat Dis. 2016 Dec;12(10):1778-1786 Oor J et al. Am J Surg 2016;211(1):250-67 DuPree C et al. JAMA Surg 2014;149(4):328-34 Rawlins L et al. SOARD 2013;9(1):21-25 Casella J et al. SOARD 2016;12(4):757-62 Barr A et al. Surg Endosc 2017;31(1):410-5

C l a p p B e t a l.

4.- PATIENT SATISFACTION

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 5.7 + 3.3 (1 10), before the revision, to the current 8 (IQR 2) (P <.011) Arman G, et al. SOARD 20 16

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